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655 Lone Oak Dr - Above ground piping test. . . ,Lof-. "' - CONTRACTOR'S MATERIAL & TEST CERTIFICATE SPRINKLER SYSTEMS - WATER SPRAY SYSTEMS PART ..A•' GENERAL / 81at / C,?l C2 ? UPON COtiPLETION OF WOAIf. INSPECf10N AND TESTB Sfi0UL0HE MADE BY CONI'RAC[OP'8 REPRfi9ENTATN6 AND WIiNE33ED BY AN OWNER'S REPRESEMATNE, : ALLD6FECI88NOULD BE CORN6Cf6D ArID eYSTEM LER IN S6RYIC6 BEFOpE COMtftACTOP'e lgN FINALLY LEAVE THE JOB. ' A CEATIflCATE SHOULD BE FILLEO OllT ANU BIGNED 8Y BOTH pEPRE6ENiATNBb. COPIEB BNOULD 0E PREPMED FOII INSPECCINO AUTNOPITIES, OH'NER AND COMRACTOR. IT IS UNDER6TODU THE OWNER•S ftEPRE5EN7ATIVE'S bICNA7URE IN NO WAY PREJUDIC63 ANY CLAIM AGAIN9T CONTAACTOR FOP FAULTY ' MAtEP7AL, POOR WORKMAN610P OR FNLURE TO COMPLY W ITH IN8PEC1'INC AV'LNOPITY'9 REpl10iEAtEM6 OR LOCAL OPDINANCES. Pf10PEPTY NA1(2kA DATE ' K?5 Ai CN ?: '7 ? ?v '10,? DdA?Qo7gcr FpaiGrrJi?f ?'/.? : ACCEPTED AY IN9PECI'10 AOT OIIITY 'S NAMES , T1:T. '51¢ 0oLLi-"" I"IdZL :?di%? G5z, /&-f /%,s? 554,02 PLANS ADDREM C170rp A/. 57145- ?1Zo7- A/e3 ? 2?A?.,?.? NO ? INbTALLA7ION COPPORhIS T0 ACCEPTED PLANe YE ? fi EqU[PM6NT USEU I9 APPROVEO Y6 No 1F NO, STATE DEVIATI0IS NA8 PER60N IN CHMCE OF flRE EQVIPMEM BeEN IN6IRUC1'ED A8 TO LOCA710N OF CONTROL .. Yfi9161? NO ? ' . VALVESANDCMEOFTFOSNEWEQVIPNENI INSTRUC- IF NO, £XPLAIN ' TIONS NAS A COPY OF INSTPUCTION AND MAINTENANCE CIWt7 BEEN L6Ff YEe NO ? AT PLANf , . - li NO, EICPLNN FLUSHINC: Flov IAe rcquVed tate unlll maim are [lear as IMinled 6y no coll¢lfan ol torelgn malerlal ln Wrlap ba[s at wtlelt sueh as hyJranla antl bb,-off:. ' . j Flush at Oove rol less Ihan 750 GPM for !-{zh plpe anA amaller. IOOU GPM for B-IncA, 1500 CPM br 10-inch. 7000 CPM far IS-inch. W here cuVVlv TE$T omwl praduee eUpulateA Ilow ro1e, abuln maMlmum anlbUie by veln properly ±¢ed dlseAargb devi[ta. - NYDH067'ATIC: NydroeuUC lot shw1E Oe mide al not leo than 300 P61 far lwo houre or 50 P5l ahave ebtle Dreuure In exceu o( 150 P51. DIlferemial tlry -pipe valve clappert rhoWE Oe lelt open Eurf., Iee1 to V«veM damage. All aEOVe QrouM piplM IeakaRe ehwld be elopped. . i DE$CRIP- LEAIUGE: New OiW lalA wlth robber gaeketeE Iolms ehoWA, If 1Ae wurkmanshlp le NllFlacbp, Aave no lobp al lhe )alnts. Vnralislaetory amoum! 0I IliA]8! Y6uilIY KEYII 1lOfll IWIEIltl, VinCAPE VE CYI g?Fkpll. NOM¢vlf, tOf11! IlaItiQ! II11R111 reeull from emall amour1e of 6rit or smail Imperfe<11one. The ammnl o( leakige a1 lhe folnte ehoulA rot excerd 2 qmrb V<r hwr prr IUO jolnle Irrerpecllv<ly ol plDe dlameeer. TAe IeaW6e shwttl be dletributed TION over a1t )mme., If sucn leaka`e oawre nt . few Jolme ?hr btulallallon ehm1E be amteldered unealb(ac(ory and n<ceepry rcpalre made. New pipe laid M I age or o wllh caulked lead or lead-svLelllute )mnlE rhould, If IAe worXmaneAip le eatlsfarbryhave Iitlle or no IeaYage a1 tAe jmnb. Any jeinl having mon tnan a"e11RM tlrip" or "we<plryi" ehoultl Er rtpaireA. Leakage eAOWE got exceed 1 os, (liqulE measure) per Aour P« IncA ol,piye dlan?cter per )oim. ' The Ieakagr ehwid 4e dlslrfbuteE over all jom,s. If eucA leaka{e occun a7mo+1 enlir¢ly a1 +(er joirts, Ih< ImUllallon shw1E be'coneldefed uneatlafaclorv aM neceteary repalre maA<. PNEVMATIC• Eslablleh 40 P51 alr preneare aM meo.vre yreeeure EroV+'hich shoulU mt ee<eeE 1 1/3 PSl ln 71 Iwurs. Teat preewra bnke m mrmal Witll ICYCIIIE Yll Prl56Y(l'. i11E 111liEVfP iIf N!!!!Y!e drOp WIIICII EIIWIU MllN1'[[A I S/a PSI 111 I4 AOVrl. ' PART "8" - UNDERGROUND PIPING ' FEEOSBLDGS. t ? LOCATION A PIPfi TYPE AND CLA89 . TYPE JOINT , UNDER- GROUND 6 ? .?? ' YE CONFORMSTO ' ST IF NO, E%PLA1N . , . . . T PIPES ' . AND JOIN78 NEEDING AHCHOPAGE CLAM1IPED, BTRMP OR BACKED IN ACCq1UANCE ? YE8 ? . -NO ? wiTx eterronan JOINTS tF'+o, EXPLMN iE5T5 ,... FlUSHING . HYDROSTATIC LEAKAGE ' REQUIRED NEW VM1EftGROUMI PiPINO FLIISIIED AC ING TO BTAfmA1tD ' - YEB ? BY (C07APANY) ' . NUV W A9 FLUSHINC FLON O BTAINED . ' ' WC WATER TANKOR RE86PVOIR ? . ' FIR6 PONP ? PUB FLUSHING TF?tOUGHWHA7TYP60P6MNG " ' _ HYD. BUtt. ? OP6N PO'6 ? TESTS LEAD-iHS FLUetlED ACCOpDINO BTANDMD YE9 ? •. ' OY (COMPANY) NON WA8 FWBIONG FI.W' OBT NED REl6RV?l ? M6 PUIfP ? PUBLIC A76R TANKqt G ?; ..? , . , " ` . ' .,. . ' • . ,• Y CONN. TO fLANCE 4 SPIGdi' ? • . OPBN PBE ? ' I, t!=t io(m No. 85 Pee. ?" NEW UtmEPGROVND PIPINfI tfYUROB[ATICA LY ?EB[EO AT HYDROSTATIC P. . TEST ?: ?'. L.. . TOiAL11DUNTO?LEAI(AC6IRABUR6D . IpUfl! o. OAIJ: . ,. LEAKAGE . . TEST ALI.OWABLE LEAKACE aAL,e. xoues NUYB[R IN6CAW,CD PC AND WIQ HYDRANTS ALLOP6RATElA178[ACtp11L7 YCB? No ? GONROI wATER COMROL YALYBd lin' NmL OPSN YE8 ? " ' No ? A76 P6ABON , IP NO, 61 VALVES DATE L6FC W eEPViCfi . , . . ' , S REMARK NAME OF BPRINIQ.ER COMAAR FOR PPOPER dVNER (BIGNED) TRLE PARTS A 8 B - FOR BPftINIQ.EP COM'RAROfl (SIGNED) DAT6 i SIGNATURES ' PART "C" - SPRINKLER 6 WA1ER SPRAY ABOVE GROUND PIPING (tiLL OUT BHPMATE PM7 "C 70R sACN PISEA) EB g -- l ? ? L'!L j"'/?-S ?L ? LOCATION ? ?K C ?D? ?,c ? aNlld/6?S ?•9 / . HYDROSTATIG TEST OF ALL PIPING TE5T5 y pNEUMATIC TEST OF All DRY PIPING REOUIRED 3 EQUIPMENT OPERATION TESTS OF ALL EOUIPMENT - TEMPEPASUPE SPRINKLERS btAKE , MUDEL gIZE QUANTITY pATING oe ? 5G ?75 SPRAY NOZZLES PIPE AND MATEAW. AND q!ID CONfQlMd7'0 B1'AtID'UID , IF NO?' E??"'?N ? • • FITTINGS ALVE ALAPY O6VICL M.WWNT116TOOPERATLTImOUGH7ECrPl% ALARMV S HEC OR fLOW TYPE . WKE MODEL MN. . INDICATOR ' D r?' rD L ?'L OPERATINOTE41'REBUL7! WATEP Nrt TRIP - TIM 71YETOTPIP pPE88. PME9l. PolN7' WATER ALARM DRY MAKE MdDEL BER. ' TlQ10UGH 7CC1' P1P6 . R6ACNLD OPLPATEO AIP PIPE N0, WITHOU7 Q. O. D. WITH Q. O. D. PRE66. T? OUTLE7 PROPEftLY IUN. BEC. WN. BEC, P.9.1, O.S.I. p.8.1. ' NIN. BEC. YES NO VALVES !F NO, EXP LAIN ' OPERATION pNEIIMAtIC ? EIECI'NIC? HYORAULIC ? DELUGE PIPING BUPEAVIeED YEq 0 13 bE76C1'ING 16DU BUPERVI6ED yEg C) Np ? UOES VALV6 OPERATE FRON TlE l1ANUAL TRIP AND/OR REMOTE CONI'NOL qTA7lON8 VEB ? NO ? a 6 TNERE AN ACCE35IOLE FACIWTY IN EACH CIPCVIT FOP TESTING YES ? HO ? IF NO, E%PLAIN PREF CTION . DOES EACN CIRNIT OPERATS OOEB EACN CII1C1112 OPEPATE MAXINUM TINE TO BUPEAVLIONLOBHAWRM VALVERELEASE OPEPAtENELEASE YALVES ?? ???L YEB NO YC9 NO IAIN. aEC. ALI. PIPING HYDR06i'ATICALLY TE@[ED A7 pA FV& 4/ ?URS DRY PIPING PNEVNATICALLY TF81'CD y 0 ?? TEST$ EOUtPM£NTOPERATEPPOPERLY IP NO BTATE RLABON 15 AA3N TEST: READING OP GAGE LOCATED NEAI1 V-ATEP B PPLY TEST PIPF: . PE6IDUAL PPEB6Uft6 Y ITH VALVE IN TEST PIPE OPEN WIDE: ETA77C PPE63URE Pel PSI BLANK ??EN llSED IACA710HB M1MB6fl AENOVED TESTING ? ' . . ' GASKETS DATL LEfT IN BEAVIC6 WR'X ALL COHIROL VALV6! OP6N. REMARKS `7 -y P 9PPINIO.BR.CONTR ?OR PRO RTY OW'N[R (0 D) 17iLC . PART ••C?• 1. SIGNATURES 8pRINKLER CONfRACI'OR IAGN6D) • N. {?? FdR ' D I?? R ???? S ?/ ? ? ...! f-.._? ? __ . . , ' CONTRACTOR'S MATERIAL & TEST CERTIFICATE : .,.,. ._:. ?....,_ , ... .. .... : SPRINKLER SYSTEMS. - WATER SPRAY SYSTEMS .... . PROCEEURE UPON COMPLETION OF WORK, INSPECiION ANO tE5T3 SNOULD,BE MADE H1f COMMCfOA'b REPHESENTATIYE AND WRNESSEO HY AN OWNEfl'S IIEPRESENTA7NE, ALL D6FEM8 BHOULD BE WrtNECIED AND BYSTEM LEFf IN 6ERVIC6 BEFORE CONTRACfOA'8 ?gN FINALLY LCAVfi THE JOB. A CERTIFICATE SHOULD BE FILLED OUT AND SIGNEO BY BOTII PEPqESEM'A7NES. COPIE6 eHOULD BE PREPMED FOR IN6PECTINC AUTNORITIES, OWNER AND COM'RACfOP. IT IS UNDERS700O THE Ou'NER'S REPRESENTAflVE'S SIGNATUflE IN NO WAY PPEJUOICES ANY CLAIM AGNN6T CONI'RACCOR FOR FAULTY ' MATEIUAL, PODP WORKMANSHIP OR FNLUR6 TO COMPLY W ITN INSPECTING AUTNOPRY'S REQUOtENENT6 OA LOCAL OADINANCES. P110PERiY NAMEC., A l:-A 5 u OATE ' 7Gn rIo S ?A Aic/ /?,,c? Po??" ?dA? ?Qo?C C?vN?j?P,?°? FAO/LT/? T` ACCF?PTED BY INSPECTIO AIIT OAITY f5 NAMES . lZ..T.. ta'?¢ coL`?i ? %?1. ?vi%? G?v /?PIT /?/rt? ?5?s9,r?2 ADDREM C'!T OFZA_ n/ PLANS INBI'ALLATION CONFORMS TO ACCEPTED PLAN9 YEF NO ? EQUIPMENT USED I9 APPROVED yE NO ? Ii NO, 9TATE DEVIATIOtS NAS PEPSON IN CHMGE OF FlRE EqllIPMENT HE6N IN6IRUCfED A8 TO LOCATION OF CONTROL Y? NO ? VALVE6ANOCM60FTW8MWEQUIPMEM . YES INSiRUC- IF rvo, E%PLNN TIONS NA9 A COPY OF INSTPUGTION AND MAIN'[ENANCE CNART BEEN LEFT YE6 NO ? AT PLAM , IF NO, EXPLAIN FWSHINC: Flow ihe requlred nte untll mafns are clear ae Indfcaled by no collecLlon ol (oreign malerlal in Wrlap W6e at wllels cucA as hydranla and M1IO4-OI(E. t Flueh at Ilove mt less lhan 750 GPM for 6drch plpe anA emalleq IOOU GPM for B-Inah, 1500 CPM for 10-Inch. 7000 CPM Ior IS-Inch. Where euVVlv TEST n^w1 proAUCe tupulaled Iiw rate, oOUin maalmum avallable by ue1K proped) eized Etsaharg< devrcee. -• HYDP037A71C: NydroEtali< leal ahw1A be mlde at nol len Ihan SUO PSI /or Iwo hwre or 50 PSI above eulle preuure In eicees of 150 P57. Dilferenllal dry-pI0e valve clappere ehwlC be lefl open durlrig Iea1 lo prevent dama6e. All above grourtl plplAg IeaksQe ohwld be eloppeC. . „ DESCRIP- LEAKAGE: New plpe lald wIIh rubber gaaketed foIMs ehould, If IM wurkmaneAlp Ir tailefaclaq, have m Italo(e at Ihe jomlw Uneallefaclory amoaffle ol lokage ueually reeull from Ivleled, yinched ur aW gaekeln. Havever, tame leakoQe mlphl rexull ftnm emall amoutit of grlt or small ImperfeelionF. The amnunl of leakage al Ihe )olnle thouid ml eaaeed R qmrts per laur per IN jolme Irreepeclivdy o( plpe dlameter. The leakage shwld be dlelributed TION over all jomte.. If sach IeaNage avcura nl a lem fo1Me Ihr Ins1a1L tlen ehoulA Ix wn>IAercA unealltUClory and neceeeary repaire mad<. Nrw ViPC laitl Wlth [aulked InA or leAtl-eubelflule jolme shoultl, 11 the workmanship le eallsfarlary, Anve IIIUe er no leakaye al lht )omb Any Jolnl having leakage or marr ihan a"aLgAl aAp" ar "weePim" ehoulE be rtpaired. LeaWRe ehould not <xcced 1 oa. (Lqu10 measure) per Mvr ptt Inch o1?ViVe Elan?eRr per /olnl. ? ihe leaMage thwltl be dlstribuleA over all Jomie. 11 euch leakaQe oacura eimml enlleely at a f<w joltia. IAe Inslallatbn ehoulG be'covldefed unutlefxrlorv AM 11[f0lE]!y leyplr! TiGl. PNEOMATIQ E.uEileh 10 V51 alr Oreneurr aM mmeure yrcesvre drop which should not exceeJ 1 t/R P51 In 31 hours. ?eal preeeure IanF[ at mrmal waler level aN air preesurc, aM measure alr preezure drop wNCh ehould rol eueed 1 i/f PSI in 24 hourr. ' PART "8" - UNDERGROUND PIPING ' IOCATION cesos eLocs. ^ A . PIPE TYPE AND CLA89 TYPE JOfNI' UNDER- ? GROUND CONFatttsio 87AN0 PD YEB ? . NO ? IF NO. EXPLAIN . . PIPES AND ]OINTB NEEDING ANCf10RAGE CLAMPED, BTRAPP OR HACKED IN ACCORDANCE - yg8 ? ND ? wrcx erervnnno JOINTS IF NO, El(PLNN TE5T5 REQUIRED .. FLUSHING . HYDROSTATIC LEAKAGE NEW 111mERGROUtm PIPINO FWSNED AC QIG 70 61'AMAIID ' . YE! ? BY (COEBANY) HOW WA9 FLUSHINC FLOM' OUTAINED ' PUBLIC WATER TANK OP NESERVOIR ? ?F/P6 PUNP ? FLUSHING TKKOUGN WHAT TYPE OP6NWG ' • , , NYD. BUM. ? OP6N PD`E ? TESTS LEADJN9 FLUBHEO ACCOHUING BTAtUlA110 YE9 ? .. t er (coMeem) .. , , NOW WAB FLUBWNG Ff,00Y 0 B7 NED ' , VUBWC AT6R Q` 7ANKdi RFJ6NVOOt ? 17H6 PU11P D ' TNqOUGN W HA7 TYP6 OPEM G [, l ` Y CDNN. TO FLANCL 4 BPIGOT ? 'OPEN PBL ? rorm no oa n<r. ALL 11EW UNDERGROUND PIPIN6 H"ROBTATICA LY TC4CED A7 FOR ' NMRS HYDROSTATIC ' v.s.l. -• TEST ? ' (bfAL NDUNT OP LeAKAGL IdABUM6D ' ' HpUpS _ OAI d . . ? LEAKAGE TEST ALLOwAeLE LEAKAGE . ' HOVPS OAId. NVMBER IN87ALL6D . 77PE AND YAIME . HYDRANTS ALL OPERAT6 BA778?ACfORILi YES ? No (] CONROL M'ATER COM'ROL VALYEB L81T Nm[ OP6N YE8 ? NO[3 ? 1P NO, 6fAT6 REABON VAWES DATE L6FT W BEflVtC6 , - ? REMARKS NANE OF BPPINKLEP CONTRACTOR 1'OP PPOPEP OWNEP (SIGNED) 71TLC PARTS A 6 B FOR BPRINI[LER CONTPACTOA (BIGtgD) OATC SIGNATURES PARt "C" - SPRINKLER S WATER SPRAY A60VE GROUND PIPING (F1LL q1T 9EPARATL PMT "C" Id[ 6ACN PISER) IOCATION 9EP Eb BLDCB. N? ?A? ?6/?? ' . HYDROSTAiIC TEST OF ALL PIPIN . TESTS Z yNEUMATIC TEST OF ALL DRY PIPING ' REOl11RED 3 EQUIPMENT OPERATION TE5T5 OF ALL EQUIPMENT _ TEMPERATUPE SPRINKLERS MAKE YODEL 91Z6 OUANTITY RATING oe XL1. F 5'O ?? l SPRAY NOZZLES PIPE AND MATeRUL AND KIrID CONIbnNS1b grAKDAltD . . . . . . IF NONE, EILPWN . FITTINGS , A L A R M D E V I C E YAIQYUM TIME TO OPERASL TIOIOVGfl TEHI' PIPB ALARM VALVE 6 LUN ' BEC. OR FLOW . NOUEL TYpe WKE INDICAiOR O(?//?yJlO/?Ta OPENATING TESf PE8U1.7B WATER A1R TRIP Tibm WA7gR ALMM TIN6 7'O TPEP PPE9B. PP698. POINf DRY (AAKE NODEL BER. 71RlOUGH T6Qi' PIP& N6AC1I6D OPENATEU AIR Tp ? ? WRNOUT WItH , ' ' PPOPERLY PIPE . Q. O. D. Q. O. G. PREBB. LL6 OU [ WN. SEC. MIN. BEC. P.B.1. O.B.I. P.8.1. ' MIN. SEC. YES NO VALVES IF NO, E%P LAIN OPERATION ppEUMATIC ? E{ECTRIC? ' HYDAAUWC O DELUGE VIPING BVPERVL9ED YES [I No 13 O6TEC17NG IWUG BUPENVIDfiD YES ? NO ? DOEB VALYE OPEPAT6 FROtl TiE MAMUAI. 7R3P AND/OR REI(OSE COMROL BTASIOHB YES ? NO ? a 45 THEAE AN ACCE3319LE PACI WTY 7N EACH CIPCUIT POR SESTING , YES [3 , NO ? IFNO. EXPWIN . ' , PREF,CTION DOES EACH CIRCUIT OPERATE ?g EACN CIACVIT OPEPATE NA%1MUM TINE TO BIIPERVI610N IA68 ALAPN VALVE RELBASE OPLRATE PELEASE VALVES MAKE NODEL YEB NO YL6 NO MIN. /fiC. E NG NYDRqTATICALLV SE81'EO AT Pm ? e ?U? ?n NC PNEUMATICALLY TLdLED Y . Y? ?o TESTS NTOPERAT6VPOPERLY ATE REAB()N ST: PEADING OP CAGE LOCATED NEAO P'A PPLY 7ESI DIFE: Rfi?UAL PREBSURE M'ITH VALVE?Q PIPE O? N WIDE: 6TATIC PPESBUnE PBl BLANK NUMBER U36D LOCA7ION8 MIMBER RLMOVED TESTING ? ?? 1? GASKETS ?U . DATE LE IN BERVICE WLfH ALL COKfROL VALVE! OP6N. REMARKS 7'7 . I , • C}'Q{ ? ?OPE 74 N6 (?D) ?R I N 77 LB ?, PART „C•' J/??"/ ?/'+' //`DOV T`6A /CI.I?NL rS SIGNATURES . roft BPPIN ER CONf0.AC1'Ql (mCN6D) ? / 0-11.n ? A ' CONTRACTOR'S MATERIAL & TEST CERTIFICpTE SPRINKLER SYSTEMS . WATER SPRAY SYSTEMS PART-"A" GENERAL PROCEDURE ' UPON COIAPLETION DF WORK. INSPECTION AND TESi9 SNOULII BE MADE BY COM'RACTOR'S REPRE9ENTATNE AND WITNESSED BY AN OWNER'b PEPfiESENTATNE. ALL DEF6C78 BHOIILD BE CORPECfED AIID SYSTEM LEFT IN SfiAYICE BEFORE CON7PAC[OR'8MN FINALLY LEAV6 THE lOB. A CERTIFIGT6 SHOULD BE FILLED OUT AND SIGNED BY BOTH REPRESENTATNES. COPIES SNOVLD 06 PQEPARED FOP IN9PECTMC AUTHORITIES, OWNER AND CONfAACTOA. IT IS I/tDERSTOOD TNE OwNEq•S PEPRESENTATIVE'S SIGNATURE IN NO WAY PAEJUDICES ANY CLA[M AGAINST CONSAAC[OR FOP FAULTY MATEPIAL, POOII WORKMANSIDP OP FA[LUPE TO CObiPLY WITN INSPECTINC AV7HOR[fY'S PEQUIIIEMEM6OR LOCAL OPD3NANCES. Pf10PEHTYNAME?iCA ` ??Q(_H 1,/ T/vC. . K ?JDATE Gn %v pappElITY ADD?,? r C?U??/1?/O.?-? F?oiGri i?S ?A A?c/ /?%/ AC'E??Y IN¢,o ??oLLs i %ZL /??,t/ -55402 ADDREM C'/?' 0,?? n/ ?'1-l'/5 ??di ?,c/?3r ?j, ??.9/? /?? PLANS INbTALLATION CONiORMS TO ACCEPTED PLANB YES NO ? YE NO? EQUIPMENT USED L7 APPHWED IF NO, STATE OEVIATION9 HA9 PERSON IN CHMCE OF ftRE EGUIPMENL BEEN IN6fPUGTED A6 TO LOCATION OF CONTHOL YE916Y NO ? ' . VALVE3ANDCMEOPTM9MWEpU1PEt6N1 ?? INSTRUC. IF NOr fi%PLAIN . TIONS HAS A COPY OF INSTPUGTION AND MAINfENANCE CIWIT BEEN LEFT YES NO ? AT PLAM [F NO, EXPLNN FLUSHINC: Flov Ihe requlred ratr unLil niafm are clear ar IMkaleG by no rollecllan of lorelan materlal ln Wrlap bap al ouUets cuch as Aydranla antl blo+-offa. Flunh at Ilowe mt lees lhan 750 CPM for 6-IMh plpe anA Smaller, 1000 GPM !or E-inch, 1500 GPM far 10•Ineh, 2000 GPM for 13-Inoh. W hcre rayplv TEST c°""ol produce etlpulated Ilaw, nte, obmln maelmum anll>ble by ueire properlY elzed AlscAarge devlces. ? HYDNOSTATIC: NyErorullc leet shw1C br mSde al ml 1<n lhan 300 P81 tor Iwo Aoure or SO P51 ahove [taUe preuure In exeees of ISO PSI. Dllferenllai dry-piDe nlve claDpere eAOUId be lefl open tluring leel lo Vrevenl Gamoge. All a0ove ¢rouM piping leakape nhwld be elapped. DE$CRIP- V p? F 1 111he rorkmaneAlV Is eallelaclorY, Aave no InkaBe a11At 1omis. Unwliefaclar1' amounls L6AIUGE: Nev 1 Iafd x?IIA rubber aeketed aIMa eLould, ol leakage ueually re!ull Irom Iw{eletl, Vinched ur cul gaskele. Nowever. mme leaka¢e ntlphl retull from small amounle of 6r11 or small Imperfectlone. 7he amounl of leabge al lh< Jofine ehould ral exaerd 2 qaarte Ver Aour per 100 jalme irreepecllvely ol pipe dlamelcr. The leakage ahwld Ge dletribe(ed TION wer all )oiinn. I( sucA kakage octvre a1 a few jmme ihe InsWllmlan ehauld be conslLercd mpUelaclory aM neceelary repalre made. N<v pipc laid k I ea aRe or with nalkeA lead or ItiA-8YO6Utulp fOlrdf EhOUIE, II lhP M'OrkTiOlIIIp I. m4alaalory, have Iillle or no leakaQe at IAe jolnle. Arry Jomi havlM morc than a"eligM Cnp" or "weeplnq' e6wid br repaired, LeakaFe shoulE gpl eaceed 1 os. (hquid mneure) per bour per Inch of,piVe tllamcter per )olnt. The lealuge ehould be dfslrlEUled over all jomV. If evch ItakaQe occurs sImnsl enlirely at a fev Joitia. lhe Inslallatlon shoulA be eoNldeYeA vnsalleGrlarv antl Mceeeary reUaire matle. ' PNEUMAtIC• EsmEllM 10 P51 a1r preeevre anE meaeure preeaure EroV Which Nauld ml ezceed 1 VY PSl ln EI homs, Tul prtesura tanke al mrmal waler lev<I aM air pressuro. vM meaeare alr pretrere Erop rAlch ahoulA ml exceed 1 1/2 %1 m 44 houre. PART "B" - UNDERGROUND PIPING FEEDS BLDG3. , 1 LOCAiION ? n f f? PIPE TYPE AND CLA&9 TYPE JOIM' UNDER- GKOUND CoNFOItMS TO STAND RD ' YES ? . NU ? IF NO, 6XPLUN . PIPE$ AND JOlN78 NEEOING ANCNOPAGE CLA20ED, eTPMP OA OACKEOIH ACCOIIDANC6 , YES ? NO? WITH BTANDM? ' JOINTS I` NO, E%PLAIN iE5T5 . FLUSHING ? -. HYDROSTATIC ? LEAKAGE ' ' REQUIRED NEW UMIEHGROVPID PIPINO FLUSHED AC QiC TO BTAtII/MD ' YES ? BY (CONPANY) ' NOJI WA9 FLUSHING FLOW 06TAINED PVBWCM'A7ER TANI[OA RESBRVOIR ? . EIA6 PUNP ? FLUSHING rMOUGH W'NAT 7YPS OP6MNG ' ' NYD. BUtT. ? OP6N PO`E ? TESTS ? .. LEAD•1H3 FLUBH60 ACCOflU1NG eTANIDAAD YES DV (COGSPANY) HOW W A9 FLUSHING F1.fTM OBT NED . PUBWC AT6ft QTANI( dt AE96RVOIR ? rM$ pVMP ? TH0.0UGH WNAT TYPE OP6M G ,+ !, Y CONN. TO i'LANG6 a BP100T ? 'OPEN PBE ? Fofm No. 05 Per. ?? ALL NEW UNDfnGROUNU PIPINO IRDR06[ATICA LY TF.61'6D AT HYDROSTATIC P. b. t. r . TEST ' . . . ? .., o TOTAL 4DUH7' O? LBANAGE IdABUN6D ' ' ? ' ' • • FMRB OAL0. . 1 LEAKAGE TEST ACI.OR'ABLE LEANAGE , . aue. xovee NUYBER lN6LALLCD ,. . . . . TYP6 AND WI¢ . . . . , , HYDRANTS ALLOPERATE8A718?ACI'ORILT yEe c Np C) CONROL WAT6P WNI'ROL VALVED Iirl' Mm[ OP6N yg9 ? ND ? IF NO' nATB ABABON , VALVES UATE L6F'1' W 86flVIC6 . .. . ` ARKS REM . NANE OFBPFINq,EP CONITA FOP PNOPER OWNEF (BIGN6D) TRIE , PARTS A & B , .. ' • - iOR BPPINIU.ER COHI'f:ACTOH (QGNED) DATE SIGNATURES PART "C" - SPRINKLER d WAtER SPRAY' ABOVE GROUND PIPING (nLL wr eeruure rAnr "c•• rax eAcx aIsea) LOCATION senvEesUncs? ?? OlIK D??D? ?/?O/L//7 ?5 r ??' 0 YDROSTATIC TEST OF ALL PIPING • - TESTS p pNEUMATIG TEST OF All DRY PIYING REQUIRED 3 EQUIPMENT OPERATION TE$TS OF ALL EOUIPMENT ? TEYPEPASUNE $PRINKLERS MAIR MDDEL 812E QUANTITY RATlNG oa SPRAY NOZZLES ?y?0 ulI PIPE AND MATLAIAL AND IOtID CONIplM6T0 srArmAnn IF woNE, ExvLuN . ' • FITTINGS ARM VA WE AI A L A R M D E V I C¢ MAIQMUN T1M6 TO OPEflASE TNROllCN TBdI' PIPE . OR FIOW TYpE MAKE NODEL WN. 9EC. INDICATOR FLd?// L?i4Td,Q /NNELL ? OPERATINC T6Sf PE9ULT8 WATER AIN 7PIP TIME TIME'f07RIP PflEB9. PPE88. pDINT WA7ER AWRN DRY MAM NODEL BER, 7101WGNTC87PIPB PEACHED DPCRATED AIN ' PIPE NO• Wr1'NOUT Q. O. D. WITH Q. O. C. PREB& 7F81 OIRLCT PPOPERLY ION. SEC. IAN. BEC. P.B.I. Y,/.I: P•8.1. ' 1AIN. SEC. YES W VALVES IF NO, f%P LAIN OPEPATION pNWNATC ? ELECRIIC? ' FIYDRAUWC ? DELUGE PIPING BVPERVIeED yu 0 No 11 D6TEC1'ING 16DlA 9UPEPV6ED yEg O NO O DOE9 VALVE OPERATE fROM TiE MANUAI. TflIP AND/OR REMOTE COMROL 6fATION9 YE6 ? NO ? 8' IS THEPe AN ACCESSIBLE FACIWTY IN EACN CIPCUI7 FOR SESTINO YES [3 NO ? IFNO, E%PWIN . . PREf GTION . DOE6 EACH CIftCU1T OPEflATE DDE6 fiACH CIACUIT OPERATE )M%IMUM TIHE TO bUPERVI910N IA68 AWPN VALVE NELEASE O?EPATE RfiLfAbB VALVES ?? ?DEL YEB NO YEB NO MN. lEC. ALL PIPING NYOR06LATICALLY 7MED AT - DPY PIPINO PNEUMATICALI.Y TE4[ED • YE9? ?O TESTS EQUIPMENT OPERATE PROPERLY IF NO 61'ATE REA80N P I TEST: PEADINC OF GAG6 IACATED NEAP Y'A R PPLY T6Sf PIPE: RESIDUAL PP683UR6 47TH VALVB IN TEST P1PE OVEN WIDE: 6TA77C PAEffiUftE ' pa, BLANK NUMMBER U9ED LACA7701O NUbmBP PBNOVFD i . TESTING GASKE 5 DA7E LEFT N BERVICE W[I'N AW. COtRROL VALV6! OPHN. REMARKS 7/17o N OP 9PPIP714.ER•C?O-N1pTACfO1? r ? "1 ` ? ? ` ? PRO R N6p 9 N6D) . ? j; - LE PART ..C.. 6 ? L. T ? ?J/i? !fK ?D $IGNATURES F6n BYW?KI'EACOMRAC7Ql(MGNED) . ? __ P• J h - /? IV _- ? CONTRACTOR'S MATERIAL & TEST CERTIFICATE -PARTS=A-& C --SPRINKLER -& WATER SPRAY ABOVEGROUND PIPING IFill Out Separate Certificate For Each Riser) t -PfiOCEDUR-E- I UPON GOMGL'ETION-OF WORK. INSPECTIDN ANO TE5T5 SHALL BE MAOE BY THE CONTRACTOR'S REPRESENTATIVEAND WITNESSEO-BV_ AN OWNER'S REPRESENTATIVE: ALL DEFECTS SHALL BE CORRECTED AND SYSTEM LEFT IN SEI7V P _ INALLV LEAVE-THE'=J06. ICE-SEF00.ECONTRACTOR'S MEN A CERTIFICATE SHALL BE FILLEO OUT-AND SIGNED BY BOTH REPRESENTATIVES. GOPIES SHALL BE GREPARED FOR APPROVING AUTHORITIES, OWNERS ANO CONTRACTOR . IT IS UNOERSTOOO THE OWNER'S REPRESENTqTIVE'SSIGNATUBE IN NO WAY PREJ- VDICES ANV CLAIM AGAINST CONTRACTOft FOR FAULTY MATERIAL GOOP WORKMANSHIP pR FA PROVIN , , ILUFE TO COMPLY WI7H AP. G AUTHORITY'S REQUIREMENTS OR LOCAL OROINANCES. PROPERTV NAME OATE P0.0PER7V ADORE$$.. -j . ACCEPTED BV APPqOVING AVTHORITY(•5) NAMES -- __ -INDU&TEi1Al R(SK:INSURERS ADORE55 - - ? PLANS ? ?? UM -INSTACL'ATION9CONFOPMS ?0.ACCE?TED=PLRivS; - -- VESn? - -NO ? EQVIPMENT USED lS APPROVED YES--? ? NO IF NO, STATE DEVIATIpNS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEENJNSTRUC7ED AS TO LOCATION OF CONT.ROL-VALVESANO-GARE-0FTHIS-NEW-EpU1P(NENT? YES Al NO G ` -!NSTRUC- . IF ?ES, GIVE NAME. IF NO,=ETSP_LAIN, . TIONS H.QVE COCIES OF APPROPRIATE INSTRUCTIONS AND CARE ANO MAINTENANCE CHARTS AND NFPA 13A BEEN LEFT ON'PREM6E57. _ YES=V,- _ NO 0--? . IF YES, GIVE NAME. IF'ND, EkPLA1N. -- HYOROSTATC: -Hytlrostatlc_tests_shall be maEe at not less than 200P51 (13.8 bars)-fortwo-hourror 50 PSL(3.4cbac5) -abovo-5ta:irpre55ure-in-axcMSOf-150-PSI-(103-oars Oift tl - - -TEST ). eren al tlry-popevalve clappers shall be-leftropen 0uring test to prevent Eamage. qll abovegrountl-piping-leakage-snall-Ce,stoppetl. DeSCRIP-. TION PNEUMATiC_ Esiablish 40 v5i (2.8-bars)air pressure-antl-measure-tlrop wnicM1-shail-not-exceed 14? BSC(0.1_bars)_in-24 hour5. Test pr855ule tdnk5 at nOrmal wate! I@V81 antl alr plessufe dOtl mea5ufa alr pfB55ufe tllop whlch shdli not 8xceetl_14e P51 0 1 ( . bars).in_p4_hours._ TESTS NVDROSTATIC: ALL PIPING. - REQUIRED ? PNeUMATIC: ORV PIPING DRAIN EqUIPMENT OPERATION: ALL, - -' --" SERVES BLOGS: LOCATION -MAnE - - '-MOOEL - 52E pUANTITY TEMPERATORE RATING SPRINKLERS U /F - 3I Z ' S-U OR - - - - _-- - = G=-= ? _ --- --?- -- SPRAV - NOZZLES 'PIPE`AND MATERIALAN0.KlND CONFQRMS TO ? _StFkNDARQ? -- "' - ---" 11`44ONE,E3EPCAIN=- ' -'--- - - -FITTINGS- -A-.L-A R M D-E V 1 C E MAXIMUM TIME TO OPERATETHROUGH TEST GIPE ALARM VALVE TYPE MAKE' MODEL MIN,_ SEC. OR-FLOW INDICATOR- FORM NS C!` vcvwcr? - ---- ----. - -- I ?v uvv.?.n_ rUK n? a rcA. IrvC_PA.90X 719.-MT. KISCD: N.Y.-10549 A ? OPERATING TEST RESULTS: MAKE M ER. TIME'TO TRIP THROUGF+ TEST 71PE WATE0. -AIR TIP p TI q?HED ALARM '. DRY NO ITHOVT WITM pRE55 AIR TEST D PIPE - Q. O. D. . PpE55. OUTLET pqOPERL MIN._ ,SEG.- - - P.5.1. P.S.I. P.S.I. MIN. SEC.- -VES- , -NO -VALVES - _ i I -NO.-EXPCAIN'-_ O'FERAT.IOFL-_ p(yEHfhA,,IC-? -=EL'ECT-RIC-O- -HYQR.4VL1r0---- PIGING SUVEFVISED: YES-fig--NO-? DETECTING'MEDIA SUPERVISEO: YES_)§, NO ? --OECUGE DOES VACVE'OPERA7E:ERQIvbT-HEMANUAL--TRIRqNO/OR=REMOT-E:CONT-RBI--STAT-IpN51---= VES-;!K,?=NO-? g IS-THERE="AN'ACCESSIBIE=FACII:ITY-IN-EACH-CIRCUIT FOR T.ESTING7 VES.-? 140.-O_ IF NO, EXPLAIN PREACTION _ VA W ES Does Eacn Circuit ooerate DW each Cir[uiLOperete Waximum Time-To MAKE MOOEL $ucervision LOSS Alefm? -VelVe ReleaSe? 0 perate'Rel¢e5e:- YES NO YES NO A1tN: SEC. -Vtitv` - _ - - - -_ _= ---- - _- - ALL PIPING HYDROSTATICALLV TESTED AT P51 FO(i-2- NOURS OitY PIPING PNEUMATICALLY TESTEO: _ • VES tL, NO ? EGUIPMENT pPERATES PROPERLV: YES ML,- -NO ? TESTS IF NO, 57ATE REASON i' °/ ' ?r.. . . .. „ ?... • ti:T : ..vn ---- . -0RRIN-"FES-T-:=qEA86NGOF_GAGEI-OCATED=---==--- .__-=-;4cSiGUACPFZESS[?R£'NfTFPV{fCVE'tN'= NEAR-WATER-SUPVCY-TEST`P1VE:- ---' ' - --TEST VIGE OPEN WIOE _ STATIC PRESSURE P51 P51 NVM9ER jiSED LOCATION$' NUNiflER..1EMOVE0. TEST BLANKS - - v VE$_• IF YES... DO YOV CEpTIFY AS THE SPRiNKLER CONTRACTOq TMAT WELQINGP ROCcDVRES=COMPLV_WITH TFiE-RE0U1RE--, M£NT,SaOF-AWS..Q309:"LEV.EL...AR.3Z_- --WELDING--- 00 -YOILGERTIPVTNAT TFi_-WELDIN?NRAS.PEqFORMSf}g?/=VFEEQERS_GVALIFI£JbINcCQM9-I NC-EM'?TM-TH?=- REQUIREMENTS OF AWS 030.9, LEVEL AR-3? --- -YES P10 ? _ ? __'_'_"" 00 YOU' CERT'IFY-TMAT=WEL.AtNG4Ui5{ARRIED=pUT-JN-COM4LIANCE?WlTH=4-40CUMEtiTED-61fRC1-T_Y-CON= - - - FROL=PROCEDORFT0-1NSUf3E-TNAT'ALL DISCS-A0.E'RETRIEVED,-THAT=pPENINGS'IN PIPING'ARE-SMOOTH; - -- TMAT"SLAG AND" OTMER WELDING-RESIOVE-ARE=REMOVED-{1NU'THAT=THE7_INT.ERNA' ALy IAMETERS OF , -P?NG-F4( " t?= PENEfPrAFE3? --_- __ CATE.LEFT'IN SERVICE WITH-Al1-_CONTROL VAL'JES OPEN: -REMARKS -_- . _...._ .. _"__ - .__-_._ - .. _____-.- - •- __ _ - - _NiCtifc6?5P(FINIGbEH--EONTRAEFO ' - _-- - -- -V 1-i?l. -` . ?- f-,'?C_.• ? F?(??'i ? _ -= f.; ?1=? - =_ ?, - FQ R-PROI+EP.TY-O N SIGNEDI"-- -"----- TiTIE - SIGNATURES=- -- 6?\l - -- - -- J ? (51G ^ -- - - - _ - - ?-_ -: - //- - ? _ - ---- - 6 - ? ? ? TE5T5'WfTNE55E09?' _! -- j =[?'_ ?TITL "DATE ?- _ -_--_?- -- LUONAtlEXPIANAIlONS-AN0.N6LE5 --_- '- _- _'_ . ? CONTRACfOR'S MATERIAL & TEST CERTIFICATE L! LJ PARTS-A=&-C--- SPRINKCEF'& WATEA'SPRAY_ABOVEGROUND PIPING (Fill-Out Separaro Certificate For-EachrRiser) "_I 4r- -PROCEDURE UPON_CAMP_LETION-0F WORK; INSPECTION-ANDTE$TSSHALlBE MP:DEBY'TFE-CONTRACTOR'S-REPqESENTATIVE AND WITNESSED BY AN OWNER'S REPRESENTATIVE A . .- LL OEFECTS SHALL BE-CORRECTEO AND SVSTEM-LEFT IN SERVICE-$EFORE CONTRAC_TOR'S-MEN ?. FINALLY-LEAVE-THE JOe. A CERTIFICATE SHALL 9E FILLED OVT ANp $IGNED BV BOTH REPpESENTATIVES. COPIES SHALL BE PREPARED FOR APPROVING AUTHORITIES, OWNERS AND CONTRACTOR IT ' . IS UNOER5T000 THE OWNER S REPRESENTATIVE'S 516NATURE IN-NO WAY--PREJ- UOICES ANV CLAIM AGiLINST CONTRACTOR'FOq F AULTV MATERIAt_, GOOP WORKMqNSHIP, OR FAILURE TO COMPLY WITH AP. PROVING AUTHpRITV•5 REOUIREMENT$ OR LOCAL OR0INANCES. PRpPERTY NAME .. /' / -DATE_ ? ? D 41J4 PROPER7V ADORE55 ED ORITV('S)NAMES = DUSTR IAL RISK 1NSUREAS PLANS INNEIIPOU3, MN 654G2 f.INSxAllAT10fV-CONF_QRM5=T0-ACCEPTEp-PCANS]- _ ..?g_ ? " EOG1Ctv1ENT USED IS-APGqDVED'- YES-? - NO ? IF NO, STATE DEVIATIONS HAS PERSON-IIV"CH"A'KGE-p?FfREEqUIPMENT 6EEN INSTRVCTED AS TO LOGTION { OF CpNTROI VAWES ANO-CAP.E_CF THIS-NEWLEGWRM11EIVT'. VES=A- NO _G " -- I IF YES, GIVE NAME. IF NO, EXPLAIN, --f14STRIIC- TIONS -HAVE.COPIES OFAPP{ZOPRtATE°INSTROCTTONS AND-CARE-AND=MAINTEfli1NGE CHALiTS ANO'NFPq-13A=BEEN7 GEFT ON-PREMISES' YES :IK-- NO-Cl IFYCS;°GIVE NAMF tF NO,_EXPLAIN. - ----- N?Y D`OS?TATIC-HytlrosCahCtesTS_shall'be-maEe-at not:less Man 200..PSL(13.8'bars) for two naurs or 50 P51 (3.4 batq- - O - ?ss?«NC'xe?of-7 50=P5 P?l'0.3=Dar5)-piffererstial=tlrY-P? Pe=valve-CtSppem_5t1alPtre-16tFOPen=tluNn?tlSt-to -TEST - Prevent-tlamage.=-AlhaEaveqrountl-pipmg-lwkaqe-.st+all-De stoppetl. _?QESGRIP- TION PNEVMATIC=-:EStaEliznui0.P51-(2.8=oan)-a¢=preszure_antlemeasuce;Omo=whicfr-Srtall-noYex¢etl.34+-P51 (0.1-bars)'-Irt24_ bOU(5. -TGSYOrGSSUfCtd11k5'dt nOlTal watar IWeI aOtl al1 pfessulB inC Teasufa di!-pfe55uPo-Grop'wtlith-Slldlf-nOrBxYeetl llh P51-(0.1-bars) m-24 nouri. TESTS NYDROSTArfC-AR PIPiNG. if REQUIREO ? -PNcVMATiG DRY-FIPING DRAIN EqVIPMENT OPERATION:_ALL. - - SEAv-ES-BlOGS: - '- - LOCATION ' _ --MAKE- -RrtOOEL -- --SIZE--"- "apKNTITV - TEMGERATURE RATING --SPRINKLERS - SPRAY _'- - - - - - - - -NQ22CES _ _PIPE?AND-. .MATERIAL-ANO KINO.CONFORMSSO: ---?ST.4NDARD- ' _ FITSINGS A L A R-M O'E V I-G E MAXIMVM'TIME_TO OPERATE THNOUGH TEST PIGE - - ALARM VALVE TVPE MAKE MOLEI MIN. SEC. -OR-FiOW= - -INDICATOfi- - (: _ I -- ---. • - --- 1.. ?-e rKIrvTEn Irv USA FOR NA5"'d FCA,-INC.. P.Q. BOX-719, MT_ KISCO.-N.Y. 10549 w - OPERATING TEST 0.ESVLTS: TIME TO TRIP TIP T? ' A?aM , MAKE M ?R. THROUGM TEST P1PE WATER AIR p EACHED OPERATEO pR? ITHOUT WITH R TEST ryp, -Q. O. D. VqE55. I vRE55. OUTl.ET ppOVERLV PIPE -MIN. SEC_ - - P.S.I. - -P5.1. P.S.S. -MIN. SEC. YES NO -VALVES - - NO, E%PlA1N - ? . - --- %ETiA-T-ION- PNEGMRT.tC%L-_- ----EtcCiRIC=O-- -- -1+yQRRUI'IC-'0 - ' - I GIPING_SUPERVISED: YES Xt NO ? DETECTING MEDIA SUPERVISED: YES la, NO ? - DELUGE =DOES-VALVE-OPER4T-E-FROM-T-MEMANUAL=T-RIC'FFNBfOR°_REMPTE_CONT0.0lL5TA-T-ION52- VES";D_ 'NO-O & IS THERE AN ACCESSL9LE-FACILITY-fNtEACN_CIRCVLT_FOR'TESLNCt VES-7L- NO _D_ IF NO,EXPLAIN PREACTION VALVES Oosz E>tb Circuit ODerate -OoeS eaGh Ciftuit Opere[C Maximum Time To-- MAKE -M60EL $upervisiOn-LOSSAIe/m7 ValveReieaSe? Op6fatrFelease: YES NO YES NO MfN. SEG. ALL 71PING HVDROSTATICALLY-TESTED-AT PSI FOR?MOURS ORV VICING'PHEVMATICALlYTE5TE0: YES ? NO ? EQUIPMENT OPERATES P0.0PERlY: ?`? •_.? YES ? NO ? TESTS IF Np,_57ATE REASON ' ;s.i••, ?Jr_ ..... ?... .:4 ' -_ '=ORAiN-TCiT:-R'E7AUI'NG-6f-?G:cuE-L-OCATcD-- =--RESIQUAt'VRESSU0.EWtTi-rVAL'V'c iT.'- -- NEAIi WATER-SUPPIY-TEST PIGE: - _TEST-PIPE OP.EN WIDE I STATIC PRESSURE P51 -psi NUMBEA" EO" ' LuCAT.IQNS- N?riuACa-RE1ytOXED_. TEST BLANKS ? "_ _ 'yy F i nEO PI PI NG "_`IES _ '"-N0 =?_ IF vES... 00 YOV'CERTIFY AS THE`SARtNKCER=CONiRACiORTHAT`WELDING pROCEDVRES COMPLY WITH THE_REQVIRE- -_---= -MENT$-OF=AWS-C#D:9? -'WELCtNG=-'- --O-YOU-CERi-IFX=T-:+FHT-T:tE-?VEL-.^.1NG=?4AScPERFOiFMfF??Y-NlEL-0ER$-E?t1i46IF1ED-FN-COMP t NCE-W4TN-THE--- _ E& NO FEQVIREMENTS-OF-AWS 010.9, I.EVEL AR-3' ti' _ ? DO-YOIrCERTIFY-THAT=WE{[QIN?W .riCP(RR cn=nIir-1N'COFIBGANCE-WAT?4'-OOCLLbtEN.LEO-QUALLLV_'CONi- TROL GROCEOl1RE"TO-INSURE THAT'ACL DISCS'A13E=RETRSEVED?TN/%T"OPENINGS-IN'PIPING-ARE`SMOOTH,-' _ RS OF TMAT SLAG AND-OTHER' WEIDINGRESIDUE-ARE=REfaOVED,=ANO TNAT-TME_INTERNAly,D1AMETE O '- DATEIEFT INSERV ICE-W iTN-Fii. CONTROL-V ALV 3-0PEN: ._. REMARKS- _ ' A-IGFE FJF-5'?R7Pl'ifC"ER C9NFR? 4CT@ t I __ - -- --- -F R-VR6?E K WNER-(SIGNED)-= "--'--- TITI'E , -SIGNATURE - - - _' ' - - - '_ -- --- - L -_-- _ " ?? p P U _ - =TE5T5' WITNESSED9V ? / y ITG' tE. DATE ? " ^^^? - ---- ? ADD IONAC-EXPI'ANA-FtONS-AND=NOTcS - - -- I I ' - - r i? . . .Ca_? / B/or-,? / C.'4j CONTRACTOR'S MATERIAL & TEST CERTIFICATE FOR ABOVEGROUND PIPING PROCEDURE Upon completlon of wark, inspection and tesLS shall be made bV tha contractor's representative arM witnessed by an owner's reprexntative, All - defects shall be correctad and sVnem ieft in service before contractor's Oarsonnel finally leave the job. A certificate shall be filled out arid signed by both representetives. Copies zhall be prepared for approving authoritiea, ownen and mntrxctc, Ic is undentoo0 the owner's represencative's sfgnaNre in no way prejudices any elaim against contrattor for faulty mamriai, paor workmenship, or tailure to camply with apOroving authority's requirements or local ordinances. PROPERTY NAME . ..'_"__' 655-a LorvF. OaK DRiv? , FAGAN ? l?7?Nil/ESOTA Ss?zZ ACCEPTEO eY APPROVING AUTMORITY(5) NAMES S?Y NlGVLLET ?31ALG 4iiTE?'6 50 PLANS SuS SSYO ? INSTALLATION CONFOftMS TO ACCEPTED PUiNS EQV IPMENT USEO IS APPROV EO IF NO, EXPLqIN DEVIATIONS AND INSTHUCTIONS HAVE ANO N IF NO? IOCATION SLOGS. OF SYSTEM L 5 VEL N NaRTH S SON / q WALx MAKE MODEL YEAROF MA UF ORIFICE QUANTITY TEMPERATURE N ACTURE SIZE RATING P GEN7"R.9G /9B? z S RINKLERS ? NTQAc? A SS Z /? I6 ? - A< <r ss? s ? i6r G E N Ra ? J / 9 f ` Y /G PIPE CONFORMS TO NF P1 STANDARD COYES ONO PIPEAND FITTINGS CONFORM TO NFI?'? STANDA(3D [?YES ONO FITTINGS IF NO,EXPLAIN ALARM ALARM DEVICE MAXIMUMTMEIDOPER4TETNAOUGHTESiPIPE - VALVE TYGE MAKE MOOEL MIN. SEG. oa F?ow V NE Nl?T/F/ER u/.?O ? qi? INDICATOR DRV VAIVE dO.D. . MAKE MOOEL SERIAL NO. MAKE MOOEL S O. E WATER AI.ARM TIME TO WATEF AIR TRIP POIN REACHED OPERATED pqESSURE ns. PRESSURE PJR E TESrOUTLET• PROPERLY DRY PIPE E NG MIN. SEC. D51 PSI MIN. SEC. YES NO OP RATI TEST Withou2 Q.O.O. Witn Q.O.D. /7 y o OYES (--]NO OYES QNO ANO MAINTENANCE CHARTS OYES ?NO 'MEASVRED FROM THE TIME INSPECTOR'S TEST CONNECTION VAIVE IS OPENED. (104so) PRINTED IN TME U.S.A. FpR NATIONAI FIRE SPRINKLER ASSOCfATION, INC.. P.O. BOX 7000, PATiERSON, N.Y. 12563 OPERATION ?PNEUMATIC ?ELECTRIC ?HYDRAULIC PIPINGS ED EIyES ?NO IDETECTINGMEDIASUPERV 17YES, r7NA vec 1 I w?r. DELUGE & IS THERE AN ACCESSIBLE FACILITV IN VIT FO IF NO, EXPLAIN PREAC710N ?YES ?NO VALVES DOESEACFiCIRCVITOPERATE CIRCUIT MAXIMUMTMETO MA MQDEL SUPERVISIOM LOSS ALARM OPENAT E OPEFATE RELEA$E YES NO YFS N IN. SEG. H V DROSTATIC: Hydrostatic tezts shall 6e made at not leu than 200 psi 113.6 bars) tor two hours or 50 psi (3.4 ban) abow statit !eei pressure in excess of 750 psi (102 han) for..wo hours. Oifferential dry-pipe valve clappers shail be left open during test to Prevent damage. All abaveground piping leakage shall be stopped. TEST F LUSHING: Flow the reqwred rete uniil water is clear as inditated by no collettion Of foreign meterial in burlap bags et outlets such as h lW l ff Fl f DESCRIPTION y raa s. ush at b owo lows not lesa than 400 GPM (1514 l/min) for 4-inch pipe, 600 GPM (2271 L/min) for 5?inch pipe, 750 GPM 12839 L/minl tor 6-inch pipe, 1000 GPM (3785 Uminl for 8•inch pipe, 7500 GPM 15678 t(minl for 10-inch pipe and 2000 GPM (7570 L/min) tor 12-inch pipe. When aupply cannot produce stipu4ated flow rates, obtain maximum availaGle. 7 UMATIC: Esta6lish 40 si (2 7 haral i e d hiM d h ll = p . r pr a swre an meaaure rop w s a not exceed 1 ,L psi (0.1 bara) m 24 hours. Test pressure tan s a[ normal water level and air Orezsure and measure air pressure drop which shall not exceed 7-'6 psi (0.1 bars) in 24 hours. ALL PIPING HYOFOSTATICALLY TESTEO AT PSI FOfl Z- HRS. IF NO. STATE ftEA50N ORY PIPINC PNEUMATICALLV TESTED ?YES ?NO EQVIPMENTOPERqYESPqOPERLY ?YES ?NO DRAIN REAOIrvG OF CaP.GE LOU\TEO NEAR WATER $UPPLY TEST PIPE: RESIOUAL PRESSURE WfTH VALVE IN TEST PIPE OPEN W IOE TESTS TEST STATICPRES$URE: P51 Underground mains and lead in eonnections to rystem risers flushed before connection made to sprinklar piping. VERIFIEO BY COPY OF THE U FOiiM ND. 858 ?YES ?NO aTNER EXPLAIN FLUSHEO BY INSTAILER OF UNDEq- GROVNOSPftINKLERPIPING ?YES ?NO &ANKTESTING NUMBER USEO LOCATIDNS NUMBER REMOVED GASKETS wELDEDPIPING EYES ?NO IF YES... OO YOV CERTIFV AS THE SPRINKLER CONTaACTOR THAT WELDING PROCEDVRES COMPLY wITMTHEREQUIREMENT50FATLEASTAWSOl0.9,LEVELAR•3 CRYES ?NO OO YOV CERTIFV THAT THE WELDING WAS PERPORMEO 8`/ WELDERS QUALIFIED IN WELDING COMPLIANCE WITH THE REQUIREMENTS OF qT LEAST AWS 030.9, LEVEI AR3 ERYES ? NO DO YOU CERTIFY THAT WELDING WAS CARqIED OUT IN COMPLIANCE WITH A DOC V MENTED QVALIT'? CONTROI PROCEDURE TO INSV RE THAT ALL DISCS AqE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTM, THAT SI.AG ANO OTHER WELDING RESIOUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF ?yES ? NO PIP N I G ARE NOT PENETRATEO HVOflAULIC NAMEPLqTE PROVIOEO IF NO, EXPLAIN DATA NAMEPLATE YES ? NO DATE LEPT IN SERV CE WITH ALL CONTROL VALVES OPEN: REMARKS - 'L? - c ZS NAME OF SPRINKLER CONTRACTOi3 MIKIN6 ,q C SPRINKLER p 7E5T5 WITNESSED BY SIGNATURES Pa R?' O ER ( D) TIT E D E J _a?-q6 - 7? i- asn eacx CONTRACTOR'S MATERIAL & TEST CERTIFICATE FOR HBOVEGROUND PIPING PROCEDURE Upon compleuortof work, inspection and testa shall ba made by the contrxtot's representative and witnessed by an owner's repretentative. All defects shall be torrected and system left in sarvice before contrector's personnel flnally leava ths Job, A certifidte sheli be filled ouc and signad by both representatives. Copia shall be prepared for epprovinq authorities, ownen and mntrac[or. It is undersiood the owner's representative's signature in no way prejudices any claim against controctor for faulry meterial, poor workmanship, or faiiure 2o comply with approving au2harity's requirements or local ordinances. . 9Y APPROVING IA! L AODRE55 S/y iv/cULLET ?lALL SuirF?'65a PLANS /N f7P G/ IJ1jNN Sa SSY07 INSTALLATION CONFORMS TO ACCEPTEO PLANS EQUIPMENT VSEO IS APPROVEO IF NO, EXPLAIN DEVIATIONS MAINTENANCE OF THtS INSTRUCTIONS AND CANE ANO MAINTENANCE C11ART5 /Z ZYES EDNO ?3YES ONO OYES ONO LOCATION ISUPPLIESBLDGS. ne evcrc.. ? Y I r I? _• ?/_ - L. V G j4V I V VK / a J OW / fV ILV&b MAKE MODEL YEAR OF MFVJUFACTURE ORIFICE SIZE QUANTITY TEMPERATUFiE RATING C'ENTRAc- /%g f /?3 2 ?/O $ 16s SPRINKLERS G ENTRAC A / 9 8 9 '? 3 Z Z /6 5 PIPE AND FITTINGS PIPECONFORMSTO NIC2115' STANOARO [55YES ONO FITTINGS CONFORM TO /1./l--A?? STANOA0.0 EgYES ONO IF NO, EXPL.41N A ALARM DEVICE MAXIMUMTIMEIOOPERq'fEiHROtX"H7ESfPIPE LARM VALVE TypE MAKE MOOEL MIN. SEC. OR FLOW VANE Nl?TiF/E/Z WF/J - INDICATOR . RY VALVE Q O.D. MAKE. MODEL SERIAL NO. MAKE MODEL S O. TIMETO WATER PRESSURE AIR PRESSURE TRIV POIN A1R E E WATEii REACHED 'fESTOUTLET• ALAfiM OPERATED PROPERLY DRYPIPE MIN,. SEC. P51 P51 MIN, SEC. VES NO OPERATINO TEST Wtthaut Q.O.D. Witn O.O.D. -' I 'MEASURED FROM THE TIME INSPECTOR'S TEST CONNECTION VAI.VE IS OPENED. /V/Nit/ ES 0 TA or' A'i1GAnj (LP80) PRINTEO IN TNE U.S.A. FOR NATIONAL FIRE SPRINKLER ASSOCIATION, INC.. P.O. BOX 1000, PATTERSON, N.Y. 12563 OPERATION DELUGE & PREACTION VALVES PNEUMATIC ?ELECTflIC Y ES MOOEL TEST DESCqiPTtON ttUS i ATIC: HVdrostatic tests shall 6e made at not leu than 200 pgi ure in excess of 150 psi (101 bars) tor!wo hours. Differential dry-p ooveground piping leakage shall be stopped. SHING: Flow the required rete untii water is clear as indicated by ni ants an blowoffs. Flush at flows not lesa than 400 GPM (1574 UR 3PM (2639 l/min) for 6?nch pipe, 1000 GPM (3785 L/min) for 8-in (7570 L/min) for 12-inch pipe. When supply cannot produce stipui: M1 ATIC: Eatablish 40 psi 12.7 Cars) air preseura and measure drop w ure tanf at normal water tevel and air pressure and messure air presa PIPING HYDtiOSTATICALLV TESTED AT 2,Ob PSI FOR _ PIPING PNEUMATICALLY TESTED ?YES ?NO IPMENT OPERATESPROPERLY I-IYFS (-lnin IF NO,EXPLA 6 barsl for tw0 hourz or 50 psi (3.4 bars) abow natic alva tlappers shall be left open during txt to prevent damsge. eMion of foreign material in burlap bags at autlets such as or 4tinch pipe, 600 GPM (2271 L/min) for 5-inch pipe, pe, 1500 GPM (5678 L/min) for 10+nch pipe and 2000 `low rates, Obtain maximum availa6le, shall not exceed 1•h psi (0.1 bars) in 24 houn. Tert Irop whith shall not exceed i-N. psi (OJ bars) in 24 hours. NpR [IF ND, STATE REASON DRAIN ncs?o'rvc? oF ca,ce LOCA NEAR WATER SUFPLY TEST PIPE: 11 RFSlDUALPRESaURE WfTN VALVE IN TESf 71PE OPEN W IDE TESTS TEST STATICPRESSURE: psI ? pgI Underground mains and lead in wnneciioru to rystem risers flushed before connection mada to sprinkler piping. VERIFIEO BY COPV OF THE U FOiiM NO. 858 ?YES ? NO OTNER EXPLAIN FLUSHED BY IIVSTAILER OF VNOEH• GROUNO SPRINKLER PIPING OyES ?NO BLANKTESTING NUMBEq USEO LOCATIONS NUMBER REMOVED GASKETS WELDING REMARKS SIGNATURES AL WELOEDPIPING CEyES ?NO IF YES... 00 YpU CERTIFY AS TNE SP(31NKLER CONTRACT00. TNAT WELDING PROCEDURES COMPLY W ITH THE REQUIREMENTS OF AT LEAST AWS 010.9, LEVEL AR-3 [2YES ? NO 00 YOU CER7IFY TNAT THE WELDING WAS PERFORMED BV WELDERS QUAIIFIED IN ' COMPLIANCE WtTH THE REQUIREMENTS OF AT LEAST AWS 030.9, LEVELAR-3 ?y ?yYES ? NO 00 YOV CERTIFY THAT WELDING WAS CARqIED OVT IN COMPLJANCE WITN A • DOCUMENTED QUALITY CONTROL PROCEDV RE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTM, THAT SLAG AND OTHER WELDINGRESIDVEAREREMpVED, ANOTHATTHEINTERNALOIAMETER50F PIP N ?YES ?NO I G ARE NOT PENETRATED NAMEPLP,TE PROVIDED 1F NO, EXPLqIN 0YES ?NO DATE LEFT IN SEi3VICE WIT H AL L C O NTROL VALVE$ OPEN: 7 Q ? l ?- 7i I ` / V - NAME OF SPfiINKLER CONTRACTOR V/KING AUTo/'y1?9TlG SPRINKLER GOM PAA/y TESTS WITNESSED BY 'R 85A BACK CONTRACTOR'S MATERIAL & TEST CERTIFICATE FOR AOVEGROUND PIPING PFiOCEDURE Upon completlonof work, inspattion and tests shall be made by the contractor's representative and witneued by an owners representative. All defects shall be corrected antl system leh in service bafore contractor's penonnel tinaliy Ieave the job. A eertificate shall be filled out and signed by bo2h reDresantatives. Copim shall be prepared for approvinp authorities, ownen and mntroetor. It h understood the owner's representativa's signature in no way orejudices any claim againat contractor for faulty material, poor vrorkmanship, or failure to comply wich approving au2hority's requiramente or locai ordinances. S- s, onrE vWk R? v& ACCEPTEO BY APP0.0VING AUTMORITY(5l NAME r zt r ? nooaess ? PLANS '??i.v .9P GLE ??A?GL?sliiT?SSS INSTALLATION CONFORMS TO ACCEPTED PLANS EpUIPMENT USED IS APP0.0VED IF NO. EXPI,AIN DEVIATIONS OF IF INSTRUCTIONS AGAN , /MNit/ESOM SS/t 0 29YES ONO ;SYES ONO ;EYES [:]NO AND MAINTENANCE CHARTS 12!9YES L:JNO LOCATION ISUPPLIES BLDGS. • OFSYSTEM 1.6 VEL 7 ORT// f S Vp T?J ??L14cS MAKE MODEL YEAR OF MPNUFACTURE ORIFICE SIZE QUANTITY 7EMPERATUFE iiATING GE/VTRAL v / 99 » 2/ 11 /6 S SPRINKLERS E/vT1?AL 14 L1 / 9y 57, 16S _ST R // sw i9BG ?P/iz 165 PIPEAND FITTINGS PIPECONFORM5T0 NF,1? STANDAf2O ?YES M NO FITTINGS CONFORM TO NF?F? STANOARO [?3YES ONO iF NO, EXPLAIN AIARM DEV ICE MAXIMUM TME TD OPERA7E THROUCH TEST P IPE ALARM A TYPE MAKE MpDEL MIN. SEC. Ofl FLOw VANE Nf?TiF/ER WF?J - INDICATOR _ Y VALVE Q.O D. MAKE MODEL SERIAL NO. MAKE MODEL S O. TIME TO WATER PRESSURE AIR PRESSURE TRIPPOIN Alfi E E WATER REACHED TESTOUTLET• ALARM OPERATED PROPERLY DRY PIPE MIN_ SEC. P51 PSI MIN, SEC. YES NO . OPERATING TEST Without Q.O.D. - Witn Q.O.D. ?MEASV0.ED FiiOM TME TIME INSPECTOR'S TEST CONNEGTION VALVE IS OPENED. ' FIRE CARE (ID80) PFINTEO IN THE U.S.A. FOF NATIONAL FIFE SAfi1NKLEH ASSOCIATION, INC., P.O. BOX 1000, PATTEFSON, N.Y. 12563 OPERATION ?ELECTRIC ?HYDRAULIC f'1- DETECTING MEDIA SUI DELUGE & I5 TMERE AN ACCESSIBLE FACILITY IN V IT FD IF NO, EXPLAIN PHEACTION ?YES ?NO VALVES OOESEACJ-IpRCUITOPERATE CIRCUIT MN(IMUMTIMETO ti1A MOOEL SUPERVISION LC65 ALARM pPERAT ?EqSE O?'ERATE RELEPSE YES NO VE$ N IN. SEC. HV DROSTATIC: Hydrostatic tests shall be made at not leu than 200 psi (13.6 6an) for twa hours or 50 pei (3.4 bars) ahove static ' pressure in excess of 150 psi (10.2 ban) for two houn. DitferenL?al drypipe velve clappers shall be left open during tert to prevent damage, All abovaground pi0??g ?eakage shall be stopped. TEST FLU H I NG: Flow cne reqwred rate until water i? clear az indicated by no coilettian of foreign material in burlap bags at outlets wch af ? DESCRIPTION d blow-of}s. Flush at flows not lesz than 400 GPM (1514 L/minl for 4-inch pipe, 6p0 GPM (2271 L/min) for 54nch pipe, hY ?a 750 GPM (2839 Llminl for 6-inch p?pe, 1000 GPM 13785 Llminl for 8-incA pipe, 1500 GPM (5878 L/mini for 10winch pipe and 2000 GPM (7570 L/min) tor 12-inth pipe. When supply cannat produce stipulated flow ra2es, ob[ain maximum available. P U ATI • Essablish 40 psi 12.7 harsl air pressure end measure drop which shall not exceed 1=h psi (0.1 ban) in 24 houn. Tert pressure tan s at nortnal water level and air pressure and measure air pressure drop which shall not ezceed 1•'h Psi 10.1 ben) in 24 houn. ALL PIPING HYDROSTATICAILV TESTED AT _ PSI FOR HRS. ?F NO, STATE REASON Di3Y PIPING PNEUMATICALLY TESTED ? YES ? NO EqUIPMENTOPERATESPFiOPERLY ?YES ?NO . DRAIN READING OF qA(:E LOCA NEAR WATER 5U(?LV TEST PIPE? AESIOUAL PRESSUR fTH VALVE IN TEST PIPE OPEN W IDE TESTS TEST STATICPRESSURE: P51 , PSI ' Underground maine and lead in connectioro to syrtem risers flushed before connection made to sprinkler piping. VERIFIEDBVCOPYOFTHEUFORMNO.858 ?YES ?NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNOER- GROUNOSPRINKLENPIPING ?VES ?NO BLANKTESTING NUMBERUSED LOCATIONS NUMBERREMOVEO GASKETS . , . wELOED PIPING EYES ? NO IF YES... DO YOU CERTIFY AS TNE SPqINKLER CONTRACTOfi THAT WELDING PROCEOV RES COMVLY WITHTNEREQUIREMENTSOFATLEASTAWSD30.9,LEVELAH•3 CRYES ONO DO YOU CEfYTIFY THAT THE WELOING WAS PERFORMEO BV WELDERS OUALIFIEO IN WELDING ?y COMPLIANCE WITH THE REOVIREMENTS OF AT LEAST AW5 030.9, LEVELAR-3 ?yYES ? NO 00 YpV CERTIFVTHAT WELDING wA5 CARRIED OVT IN COMPLIANCE WITH A • DOCUMENTED qUALiTY CONTRpI GROCEDUHE TO INSURE TMAT ALL OISCS ARE RETRIEVEO, TMAT OPENINGS IN PIPING ARE SMOOTH, THAT SIAG AND OTME0. WELDINGRESIOVEARE0.EMOVED.ArvOTNATTHEiNTERrvALDIAMETER50F JRyES ?NO P P I ING ARE NOT PENETRATEO HVDRAULIC NAMEPLqTE PROVIOED IF NO, EXPIJIIN DATA NAMEPLATE YES ?NO ?ATE LEFT IN SEVICE WITH AI,L COIVTROL VALVES OPEN: -Z^ 7 -9-6 REMARKS I NAME OF SPRINHLER CONTRACTOR v u p c SPRIIYKLER o TESTS WITNESSED BY SIGNATURES ?PR??T'/ OW En (SIG?lEW) I' A??i? I /1 Y ? ?7?JL?_1? ?\ -Q/(_ V ??? 1 -t ? V Y\ /?ln?w? ivQ. I lO/ .-1,)IQI 1 BSq gqCK CONTRACTOR'S MATERIAL & TEST CERTIFICA7E FOR L.?BOVEGROUND PIPING /'-\ PROCEDURE ' Upon compleoonof work, inspection and tests shail 6e msde by the eontroctor's representatiw and witnezsed W an owners representative. All detecu shall be corrected and system leh in service befora contractor's pereonnel tinally leave Ne job. A certificate shall be filled out and signed 6y both representativea. Copies shall 6e prepared for approvinp authoritiea, owners and contractor. It is undencood the owaer's represencative's signature in no way prejudices any claim againat tontrettar for faulty material, poor workmanship, or tailure ta comply with approvin9 authority'e requiraments ar local ortlinancas. - S- LowE OAK Riva EAGAN ^AlNESorw SSlZ2 ACCEPTEO BY APPROVING AUTHO(SITV(5) NAMES 1X?1 ? GrT or raGA? AODRE55 PLANS S? ti?AP GLE ???LG?a!/i/?SJ'Y Z INSTALLATION CONFORMS TO ACCEPTED PLANS _ OYES [:]NO E4VIPMENTVSED tSAPPROVEO OVES C:]NO IF NO, EXPIAiN D@VIAT10N5 STRVGTEDNSTOLOCATIOIV OYES UNO OF THIS NEW EGUIPMENT INSTRUCTI ONS HAVE COPIES OF qPPROPRIATE INSTRVCTIONS ANO CAi3E ANO ANO NFPA 13A BEEN LEFT ON PREMISES IF NO, EXPLAIN CNAR75 LOCATION SUPPLIES BlDGS. OF SYSTEM ?J r_ L F_ L ? A1,00 IW a Sea TN AIAG JC0 MAKE MODEL YEAR OF ORIfICE QUANTITY TEMPERATUFIE MANUFACTURE SIZE RATING GENTRAL SS 19B 9 /%3Z .39 A6.'?--? SPRINKLERS NTRAL ? S 1? ? B S 1 1/?3 Z Y Z 16 GENT?AL f1 SSGI / 7R S 77:1Z Z ?C7 S GIPECONFORMSTO NFRH STANOARO &YES ?NO PIPE ANO FITTINGS CONFORM TO Nr-15?5' STANOARO [5?JYES ONO FITTINGS IF NO, EXPtAIN ALARM OEVICE MA%IMUMTMEi00PERATETHfiOUCHTES'TPIPE ALARM VALVE TVpE MAKE MOOEL MIN. - SEC. oRFtow VANE NUT/F/ER i.?A-0 - INOICATOR ORY VALVE a.d ?. S ? , ? MAKE MODEL SERIAL NO. MAKE MODEL E WATER ALAFiM Wp'TER AIR TRIP POIN AEACHED OPERATEO TIME TO PFiESSURE PRESSURE AIR E 7Ey70VTlET• PROPERLY DRY PIPE MIN.. SEC. P51 -00 P51 MIN, SEC. YES NO - OPERATING TEST Withaut O.O.D. witn Q.O.D. 1\V? "MEASURED PROM THE TIME INSPECTOR'S TEST CONNECTION VAIVE IS OPENED. QO430) PRINTED IN THE U.5.0. FOF NATIONAL FIRE SPRINKLEF ASSOCIATION. INC., P.O. 80X 1000, PAiTER50N, N.V. 12563 ?ELECTRIC ?HYDRAULIG (1??n DETECTIhG MEDIA SU{ DELUGE & I5 THERE AN ACCESSIBLE FACILITV IN UIT FO IF NO, EXPIAIN PREACTION [JYES ?NO VAIVES MA MOOEL OOESEACMCIRCUITOPERATE SUPER41510NLC65ALARM CIRCUIT pPcRA MAXIMVMTIMETO OPERATERELEfUE YES NO YFS N IN, SEG. HY2R2STATIC: Hydrostatic tens shall 6e made at not less than 200 psi (13.6 bars) for two hours or 50 psi 13.4 ban) above static ' pressure in excess ot 150 psi (102 6ars) for two hours. Differentiai dry-pipe valve claPPers shall be leh open during test to prevent damege. All aboveground piping leakage shall be stopped, TEST FIUSH I NG: Flow the required rate until water is cleer aa indicated by na collettion ot foreign material in Curlap bags at outlets such as OESCRIPTION hY rancs an blowafts, flush at fiows not less than 400 GPM (7514 l/min) for 4-in[h pipe, 600 GPM 12277 Umin) for Svnch pipe, 750 GPM (2839 L/min) tor 6inch pipe, 1000 GPM (3785 Vmin) for 8-inch pipe, 1600 GPM (5678 L/mm) for 104nch pipe and 2000 GPM (7570 L/min) far 12•inch pipe. When supply cannot produce siipulaced flow ra[es, o6tain maximum available. PN UMA71 C: Establish 40 psi (2,7 bars) air pressura and meawre drop which sha11 not exceed 1=.5 psi 10.7 ban! in 24 houn. Teat pressure tan z at normal water level and air pressure and measure air pressure drop which shall not axceed 1•X psi (0.1 bars) in 24 hours. .4L1 PIPING NYDROSTATICALLY TESTED AT ?PSI FOR ' HRS. IF NO, STATE REASON DRVPIPINGPNEUMATICALLYTESTED ?YES QNO EQVIPMENTOPERATESPROPERLY ?YES ?NO DRAIN REAOING OF GAGE LpC.qT NEAR WATER SUFPLY TEST PIPE: pE51WAL PR65URE WfTM VALVE IN TEST PIPE OPEP! W I OE TESTS TEST STATICPRESSURE: pSl ? PSI Underground mains and lead in connections to syrtem risers flushed 6efore connection made to sprinkler piping. VERIFIED B`/ COPY OF THE U FORM NO, 858 ?YES ? NO OTHER ExPIAIN FLUSHEO 6Y INSTALLER OF UNDER- GROUNDSPRINKIERPIPING ?YES ?NO BLANKTESTING Nl1M8ER USED LOCATIONS NVMHER REMOVED GASKE75 . WEL,DEDPIPING EIYES ?NO IF YES... 00 YOV CERTIFY AS THE SPiiINKIER CONTRACTOR THAT WELDING PROCEDV RES COMCLY w171i THE REpUI IiEMENTS OF AT 6EAST AWS 030.9, LEV EL ARd CRYES ? NO DO YpV CERTIFV THAT TNE WELDING WAS PERFORMEO BY WELOERS 4UALIFIED IN WELDING COMPLIANCEWfTHTNEREqUIRENENT50FATLEA5TAW5O30.9,LEVELARd ERYES ?NO 00 vOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMCLIANCE WITH A OOCUMENTED QUALITY CONTRQL PROCEOV RE TO tNSURE THAT ALL DISCS ARE RETHIE4E0, THAT 07ENINGS IN PIPING ARE SMpOTH, THAT SIAG ANO OTHER WELDINGRESIDVEAREREMOVED,ANOTHATTHEINTERNALDIAMETERSOF ?!]YES ?NO P P I ING ARE NOT PENETRATED HVDRAULIC NqMEPL,ATEPROVIDED IFNO,EXPI.AIN DATA NAMEPIATE YES ? NO un l e IEFT IV SERVICE WITH ALL LONTROL VALVES OPEN: REMARKS - Z'7 r 76) SIG NATU R ES TESTS WITNESSEO BY esn eacx CONTRACTOR'S MATERIAL & TEST CERTIFICATE FOR AOVEGROUND PIPING PROCEDURE Upon compleuon of work, inspectlon and test> >Aall be made by the contractor's representative and witnessed by an owner's re0resemative. All defeces shell be corretted and system left in service beforo con2rector's personnal finallV leeve the job. A certitipte shall 6e filled out and signed by both rapresenatives. Copiea shell be prepared for approvirp authoritias, ownen aM eontnetor. li iz undentood the owner's representetive's signature in no wey prejudicas any ctaim against mntrattor tor faulty material, poor workmenship, or failura ta compiy with approving authority's requiremenu or laeal ordinaneea. BY PLANS INSTRUCTIONS GUG LET INSTALLATION CONFORM5T0 ACCEPTEDPLANS EQUIPMENT USED IS APPROVED IF NO, EXPIAIN OEVIATIONS HAS PERSON IN CHARGE OF FIRE EQVIPMENT BEEN INSTP.VCT OF CONTROI VALVES AND CARE AND MAINTENANCE OF THIS IF NO, EXPLAIN 1 F NO. I !1(:ATIf1N ISUPPLIESBLOGS. A6/9N , /rJ1Nit/ESoT.? SS/Z2 iTy o CARE ANO NO OF SVSTEM ` a, L GvGl. NOR T T S ON MAKE MODEL YEAR OF OHIFICE pUANTITY TEMPERATURE MPNUFACTURE SIZE RATING GEN RAL S ? /999 ` )4 6 SPRINKLERS 5 A/ 7-4 AL 19 g ?VI 3 Z. / 6 CE NTRA e- 0. s 7? Z G IvrR? 5 a 1 5 Sy 6S C ENTRAL JP / 5 ' 6S PIPECONFORMSTO NFP/a STANDARO to YES ONO PIPE AND FITTINGS CONFORM TO N/--YVA' STANOARO (52YES ONO FITTINGS IF NO,E%PLAIN ALARM DEVICE MAXIMUMTIMEiDOPERATEiHROUGHTESiPIPE ALARM TYPE MAKE MOOEL MIN. SEC. OHFLOw v niE ni07/FiEA wFo - INDICATOR DFV VALVE C.O.D. MAKE. MOOEL SERIA4N0. MAKE MODEL 5 0• E WATER ALARM TIMETO WATER AIR TRIPPOIN RFACHED OPEFATED ppE55URE PRESSURE AIR E TESfOUTLET• PFOPERLY DRY PIPE MIN.. SEC. P51 P51 MIN, SEC. YES NO - OPERATING , TEST Without Q.O.D. wisn Q.O.D. ir rvv, •MEASU0.ED FROM TNE TIME INSPECTOA5 TEST CONNECTION VALVE IS OPENED. OYES []NO ?SYES ONQ 0.0.80) PRINTEO IN TNE U.S.A. FOR NATIONAI FIRE SPflINKLER ASSOCIATION, INC., P.O. BOX 1000, PATTERSON, N.Y. 12563 PERATION ? ?PNEUMATIC C?ELEC7RIC DELUGE & IS THERE AN ACCESSIBLE FACILITY IN UIT FO IF NO, EXPLAIN PREACTION ?yES ?NO VALVES UOESEACNppCU1TOFERATE MA MOOEL SUPERVISIONI OSSALARM CIRCUIT mAXIMUMTIMETO OPERA OPERATERF1EJi5E YES NO vE5 N IN, SEC. HYDROSTATIC: Hydrostacic tests shall 6e made ac not lett than 200 Psi f 13.6 banl for two houn or 50 pzi (3.6 bars) above statie ' preaure in ezcess of 150 Psi (102 bars) For !wo hours. DiHerential dryyipe valve clappers shatl be leh open during test to prevent damage. All aboveground piping leakage shall be stopped. TEST F-lU$ HING: Flow the required rate until watar is clear as indicated by no coilettion of fpreign material in burlap hsgs at outlecs such aa h ? s DESCRIPTION Y ra nt and blowofts. Flush at flows not less than 400 GPM (1514 L/min) for 6•incA pipe, 600 GPM (2271 Llmin) for 5-inch pipe, 750 GPM (2839 L/min) for 6-inch pipe, 1000 GPM 13785 L/min) for 8-inch pipe, 1500 GPM (5678 L/min) for 701nch pipa and 2000 GPM 17570 ?/min) far 72-inch Pipe. When supply cannot produce scipulated flow rates, obtain m?imum available. PN MATIC: Establish 40 psi 12 7 bars) air pressure and measure drop whie? zhall not exceM 1=f 1 b s) in 24 h i (0 T . oun. i ps . ar est pressure tan s at normal water level and air pressure and measure air pressure drop which shall not exceed 7-'h Psi (0.1 bars) in 24 houn. ALL PIPING NYOROSTATICALLY TESTEO AT PSI FOR ??HRS. ?F NO, STATE HEASON DRY PIPING PNEUMATICALLY TESTED ?YES ? NO EQVIPMENTOPERATESPRpPERLY ?YES ?NO pRAIN READING OF GAGE LOCA NEAR WATER SUPPLY TEST PIPE: RESIOUAL PR RE WITFi VALVE IN TESf PIGE OPEN W IDE TESTS TEST STATICPRESSURE: PSI p$I Underground mains and lead in connections to system risers flushed before connection made to sprinkler piping. VEHIFIED 8Y COPV OF THE U FORM N0.858 ?YES ?NO OTHER EXPLAIN FLVSNED BY INSTALLER OF UNDER• GROUNOSPRINKLERPIPING ?YES ?NO BLANKTESTING NUMBER USEO IOCATIONS NUMBER REMOVEO GASKETS WELDEDPIPING EYES ?NO IF YES... DO YOV CERTIFY AS THE SPRINKLER CONTRACTOR TNAT WELOING PROCEDURES COMVLV WITNTHEREQUIREMENTSOFATlEA5TAW5D30.9,LEVELAR•3 5?YES ?NO DO V6U CERTIFYTHATTME WELDING WAS PERFORMED BY WELDERS QUALIFIED IN WELDING CpMPI.IANCE WITH THE 0.EqVIREMENT50F AT LEAST AWS 030.9. LEVEL AR3 [RYES ? NO 00 VOU CERTIFY THAT WELOING WAS CARft1ED OVT IN COMPLIANCE WITH A - OOCVMENTED qUALITY CONTROL PROCEDURE Tp INSURE THAT ALL DISCS ARE RETRIEVEO, THAT OVENINGS IN PIPING ARE $MOOTH, THAT SLAG AND OTHE0. WELDING RESIOUE AHE REMOVEO, AND THAT THE INTERNAL DIAMETEAS OF ;RYES ? NO PIP N I G ARE NOT PENETRATEO NYORAULIC NqMEPV1TE PROVIOED IF NO, EXPIAIN OATA NAMEPLATE YES ? NO DATE IEFT IN SERVICE WITH ALL C ONTROI VALVES OPEN: REMARKS \ - - V NAME OF SPRINKLER CONTRACTOR I VIKIN6 U A G SPRINKLER 0 TESTS WITNESSED 8V SIGNATURES R PROPER Y NER (SIGN D) TITLE TE D A r / ? ?(( TITI_E NOTES ui+ 1. SSA BACK ?., , ? CONTRACTOR'S MATERIAL & TEST CERTIFICATE ED -RARTS-A°&-C --SPRtNKCER-& WATEFI-SPRAY ABOVEGROUND PIPING=1Pilf-Out Separate-Certificate For Each Riserl- -7 -Q-A- 7 -Wj-- m... .: -,-. - ?..? .-....---?--- - --?? •- PROCEDLRE_._ UPON COMFIET.tOIVOF WORK,.INSPEGTIOI`?AND-T-E5T5-SMRCC.BE'MAOE BY-THECONTpKCTOR'S REPRESENTATIVE AND-WITNESSEO BY I ' AN OWNER S REPRESENTATIVE.__ALL OEF_EGSS SHAII._BE CORRECTED-AND 51'STEM LEFT-IMSE0.VICE8EFORECONTRACTOR'S MEN I FINALLY_LEAVE THEJOe. , A CERTIFICATE SHALC BE'FILLED OUT AND SIGNED 8Y BOTH REPRES£NTATIVES. COPIES-SHALL'BE'PREPA'RED FOR qVVROVING " AUTHORITIES, OWNERS AND CONTRACTOR. IT I$_UNOERSTOOD TME OWNER'S"REPRESENTATNE'S SIGNATUREIN NO WAY PREJ- - UOICES.-HNY GLAIM-AGAINST CONTRACTOR Fp'0.--FAUCTY MATEf3tAL, POOP WORKMANSHIC, OR-FAILURE TO COMVLV WITH AG- PROVING AUTHORITY'S REQUIREMENTS OR LO CAL OROINANCES. PROPERTV NAME OATE PROPER7Y ADORE55 ,ZS .J c..? ACCEPTEO BY APPROVING AUTHOkITVI'S) NAMLS INDUSTRIAL RISK INSURERS -nooaESS ?j?(?( WALL VSUITE- PLANS MINNEAPOU.S? MN 66002 - - t-INSSr.46A-FION-G:JNF4RM5 TO-RC:E?Tcv-arpJL$_ `EQIrtPRtENT=US ' EO IS FPGqOVED YES-?- -NO ? - IF NO,'STATEOEV IATIONS MAS PERSON-IN-CMARGe OFF12E"EQLJTPMENT'3EEN INSTRUCTED AS TO.LOGATION I OF CONTROL VqLVE5-AN0-CP.RE OFTMIS NEW_EwIiIPMENT3' VES=pt--- - NO-Cl- IF YES,-GIVE-NAME. IF"NO, EXPLAIN. -1NSTR -- U?? -- TIONS? "HAVE_COPIE5=0FAPPqOPRIA4E-INST-RUCI6N5 ANO CARE AND=MAYNTENANCE -- CHAfFT-S-AND NFPp 13A8EEN LEFT ON'PP.EMISES? YES_X NO -Q -'-"- IF'YcS:rGWC-NAM£.-IF-NOiT'EXPLAIN. - - - HYDROS'f-ATICr-HytlrosiaUt teztz-ShalY'Crmatl<at-not-less than 200-P51'(13.8_-DarsootLtwo houts 0r__50.P51 (3.4bars) I :aba?siaEi?cy.4ure-.rKexcgy?p(-?SY-P.gl=(7-Y':oars):c=Uitixe+rciattlt.y-ptpealvccbpperfshall'be-left-open Eurinq testro T.EST Prevent-Eamage,- AII-abovagrounE-piping-ICdkdge-sha1F pe-stoppetl. - - 6ESCRIP=--- TION -0NEUMATG cstxbli511-60 G51.(2-8_Ears) air_pressuee dnC mealure-Crop_whlCh=StrtlL-nOtezcseC_1?h-F51(0.1-bac5}-m-24 - -hourS.-TesY0reS5ure'tanks-aYnO/mal-wafer Ievel.dnC-aircpromrG-anC=mtasufe=iir 'pF655uro'Cr0p wtrltn.Shall Oot-a%CesE-1Vt P51 (0.3_bars)-in.-24-nours. ---'TESTS--- --"--- - ' - -'-~-YTY'TOSTATIC-AL'L PYPING.-""'- ?l1 REQUIRED P?'1EUMATIG_ORV PIVING ORAIN - EqU1PMENT 07ERATION: ALL,. --- -SERVES-HtDGS: --- - ' '- - LOCATION -_MAKE---' --R1pDEl=_ -SIZE' -- -" -'-pUYCI4MY-'- TEfNPE1tATllRE'-RATING SPRfNKLERS - k Sv - SPRAY - - - - - - - N0221ES ---- - -=-PfPE=.KND--- 'N'tASERIAL="ANo-KIND-CANFORMS_i0 .' ? -STANDARD""'-" ' FITTINGS R L A R M- O-E V I C E_ MAXIMUM TIMETO'OG6RATE THROUGM TEST PIPE ALARM VAWE TYPE MAKE MIN. -SEC. OF FLOW. ??- UAIIT?D-E -INOICATQR-- -rvnm aa Aq KtVISED-APRIL 4979 _ BRINTED IN U.S.A. FOR CIAS-6'FCP.;-ING,-RO' BOX.739:M7. YVSCO. N.Y.10549 r ?c? OPERATING TEST RESULTS: MAKE ' TIME TO TRIF THROVGM TEST CIVE WATER Alq TIP TI E? ALARM ORY NO I7HOUT WITH pRE55 IR TEST D POPE Q. O. 0. . -PRE55. OUTI.ET pROPERL = -MIN: -SEC.- - P.S.I. -P5.1. -P:5.1. -MIN-. ?SEC. '-VES- ?-NO' -VALVEfr -- - - OPEAAT-ION--_ - ___-pNEtlNh4`i'IC0 = EtECrRtC'J'- _- _-FiVDiCKUCIrO - SVPERVISED: YES ? NO O OETECTING MEDIA SUPERVISED•-- ES-:O--'-NO. O` DELUGE ' - - ' OOES=?sPrtVEO =FROMTME=MRNLLAL-SR4P=qNO/OR-REMOTE_CONTR - - ION$?°= -' 'VES-?- - -Np=O= -IS i-NERE AN ACCESSI6LE_FACILLT GH CIRCLLIT . 571NG1- YES -O-- -NO=O_ IF NO, E%PLAIN PREACTION VAWES ' Doas EacD ClrcWt Oaenta- -Does- ccuit Operet!- Max'xnum Time To MODEL Supervision Loss Alarm7 Valve fle Ope2te Releese. YES NO YES NO SEC. ALC-PIGING HvDROSTATICAILY'TESTED AT /LrC? G51 FOR-2 - HOVRS DRY GIPING-PHEVMAT.ICALLV T.ESTED: , , ,. • YES ? -NO ? . -EAUIPMENT OPERASES PROOERLY.:- YES ? - NO-? TESTS IF NO,_STATE[REASON' ' --: ==- =6.7-A;(tFCST-=?Tc:cDiNG=OF=GA'GE-L'OCF7ED--- - ---'q'3YOVFGPf?EaSUF?WITH=VA'LV-E-1lJ-- -- "- " - -NEAR WATER'SUPPCY-TEST-PIPEC-?-' - -'TEST-PIPEOPEPfWIOE STATIC PRESSU0.E P51 -P51 NUMBE - R. _ _ LqCAT_IONS_. __ . _ N.UMgE[LREM6VEO TE57 BLANKS _ -. [Do-YOV=CERT_IFY-AS THE SP0.1NKLER GONTRACTQR THAT WECDING_PROCEDURES.COMPLY-WITH THE-REQUIRE--- _ vES=A-' -='WELD'NG-"=- -00-YOV-CERT-LF?TH?I?T.H?-W4(+-J+A??-WAT.-0ERF6iiMED_E4`f=N'E'--`LIER-5-0UA1-IFfEEI>afv=COhtP-i C?-WI-T'+T,-tE_ _ REQVIREMENTS-OF AWS-010c9, LEVEL AR-3? YES- NO ?" -' __? __ =D0-YOU=CERT:IF_WTHAT_wE[.QING?N - N1En ntrt ?M-COMGl.1.4NCE_WL2N_.4_O pC{;tMELiT.E01yUALI?CAN- __- TROL-PROCEDl7RE'-TO'INSUqE-i'HATALL DISCS-FCRE (iETRlEVEO,-THAT-OPENINGS IN PIGING-ARE SMOOTH ? THAT-SIAG AND=OTHER'WELDING RESIOUE ARE-REMOVED„AND THAT TME _ INSERNA'CIAMETERS OF - ? - ?FNG_FYRENtS'?ENELR-lLrE6 ??_ , _ `- ,,?? _ N° =?_ - i ?'J??E_IEPS-IN-SERVtCEWITN-ALLCON.T-ROL-VAWESOPEN: ' ° A K5 _. - ER-CON7`RACTOQ-- - _ - - -=r? _" - - _ _ "FO_ p PEftTY'-OWREfir(S NEC)_- - - '_ _TITIE - =51GN.4TURE5 -- _ " -" _ _'_ _TE575_WITNESSED=B.Y_-_ _' - ' - 'TITLE D.-=DATE==°,..=--.i---- --_'_ Ot ONAL=EXPCRKAT•tONS=A1YD=NOF.J-- - - _? _,. _'----_-.- ,-- . r . t: _ . . . . : ?.: . . .._ . . ::;_ -._. r CONTRACTOR'S-MATERIAL & TEST CERTIFICATE LJ LJ 'PARTS-R-& C-SPRYNKCER-&=WATER-SPRAV ABOVEGROUND PIPtNG IPiIL.Out.Sepante-CertificateFor_-Each Riserl ?7!0 r> P-.& '7 - ' _ _- ?-'' ? ? ' - .-F-?C-1- __41 1 G1+'P IPROCEDURE_ LPON. GOMPLETION-OF.WQRK,INSPECTION-ANO T-ESTSSNALL BE MADE"BY THECONTRA'CTO(i•SiiEPHESENTATIVE AND WITNESSED BY ' - ' AN OWNER S REP0.ESENTATNE -ALL DEFECTS SHALL BE.CORRECTED AND SY57EM-CEF-T-IN-SERViCE 9EFORE GONTRACTOR'5 MEN FINALLY=LEA V.E=T-HE_J06._ ACERTIFICATE"SHALL BE FILLED OVT AND SIGNED BY BOTH REPRESENTATIVES. COVIES_SHALL 9E PREP{i0.ED FOR APPROVING . AUTHORITIES, OWryERS AND CONTRACTOq. IT IS.VNOER5T000 THE OWNERS REPRE$ENFATIVE'S SIGNATVRE IN NO WqV PREJ- UOICES-ANY CLAIM AGAINST CONTRAGTORFOR- FAVLTV MATEt31AL,-POOP WOFKMANSHIP, OR FAILURE TO COMPLY WITH AP- PqOVING AUTHORITY•5 REQUIPEMENTS OR LOCAL OROINANCES. PROVERTV NAME ' } DATE N g PROPER7V AODRE55 //' "ACCEPTED"BY-APPROVWG AUTHORITV('S) NqMES- 1NDUSTAIAL- RISK INSURERS -AODRE55 i - -u, V1 - PLANS MINNEAPOGS; MN 6,r102 ' -It154-A_? _ATION=CONFCRY.NS_= O::.L:.F32u7so?_4N5:--. ___ __ YP?i?-'_ -_"M0.? - EOVIPMENT=VSED IS APPqOVEO VES ? NO ? ? IF NO,.STATE DEVIATIONS MAS rER50N'IN-CHARGE-OF-FIREEQUIPMENTSEEN- IIVSTRUC7ED AS TO LOCATIOIV Of CCNTROLVqLVES-AFJO r,qpc OFT-NIS-MEW-EQUIPMENT?__ VES=?- NO ? IF-VES, GIVE NAME. IF NO, EXPLAIN, =1NST.ROC- - TIONS HAVE.LOPIES+OF A?PROPRIATE INST-RVC7fONS°ANO-CAfiFANO:MAiN7ENANGE p.r CHARTS ANO NFPq-13ABEEN_CEFT-ON"PHEIG1f5E$? ?- YES yi "NO ? IFYES; GIVE°NAME.--IF-NO, c%PCAIN.- --- -HVDFOSTiiTIC:°-Hyarostatitrtestrshali-be-madl=arnot=l<ss-tran'200-PSr"(13:e.bars)_for-twa hour5 or_SC P51 (3.4 bars) - =abev?s*s+.*-n..ee..GG????s?T50=P:1-(:Q=,i=bdt5?-01 ifor¢ntaL-G[yp?Pe'-oJWO'?CKppGrFSh2?Y-bv?7HYQDa?=QU?ln9°idt.t0 I TEST__ _ Preventtlamage. :All.abov<qroun0-p{pingziwkaqe--ipall-E"e-4tapp00:= " _ --DESCRIP ?- 'ION PNEUMAT!C_ EiWlisn 40 P51_(28--GNS) dIF.0rB5,lrB-dPO-TGSUI!=tlroO-M`biCtl.Shill.IIOL.HeCLlG_SBt..P51_(0,1-bdfSS-?? 24 - - bours: -Tes[-pressura-Lanks=at-normahwater level antl air preszutn antl mmwro air praswrc Orop whicn shall noEaxceetl 114 P51 (0.1 bar3) m 24 nours. ___.. -TESTS---- _--- "- H'/D'ROSATIC:-Kl'CGI7tNaC`. --_-"_ - ?!a I REQUIflED -PNEUMATIC: DRV GIPING ORAIN ' EQUIPMENT OPERATION: ALL, _ _ SEi?VES-BtDGS: '- LOCATION - --=MRIEE- --MODEL.- --SIZE-- -pUANTI7Y- eMPER'ATIIRE=RATING -SPRINKLERS _-0R ,SPRAY --N022CES----- - - -PfPE ANQ--_ MATERIAI_ANO KIND CONFORM5-2 - - ? - STANOARD='-- - - - FITTINGS--- A-L A iF M' 'D E V I G E M3IXIMUM TIME T60PERATE THRdUGH TEST PIPE AL4RM VALVE- TYvE MA1c@ MIN. SEC• - _OR_ FLOW_ - - h7 S- - -INOtCA70R- -rutem aD'AG,_ REYISEO. AVFIL 1979- PRINTED INUS.A. FOR NA$ 6 FCA._INC., P.D. BOX-739. MT..KISCCI. N.V. 10549 - OPERATING TEST RESUlTS: DRV MAKE M ER. TIME TO TRIP THROVGN?ESTiIPE WATER A4R 7?p p TI ' EA MED AI.ARM- NO. l THOUT WITH PRE55 iR C TEST ?PERATED - PIPE Q Q 0 . pqE55. OUTLET vROPERIY -VAL'JES .MIN. SEC: P5.1:" G.SJ. MIN,- SE0. - -- YES NO - _-_ -- - -NO. EXPLAIN" -"?-- - . - ?- ? - 6PERA-FION---- ---PIYEQAM1ATIC O- - -.ELECTRIC_O^-'--?- -HY6RAUGC-Q"' -PIGING SVVERVISED: vE5 ? _ _NO. ? OETEGT_ING=ME0.tA=5VDER-VISED: -VES--O---NO ? DECUGE- - 'DOESV=ACYE=OPERA-FEFRpMTME'MANftALTRfV KND/QRTAEMpTE'C6MTROL STATtON ? ? S? YES NO -$,- IS-THERE AN ACCE$SIBLE FACIIITY IN-EAC'1{Ii7EUPT-FOR-TEST/NG?YES 0 'NO ? IF NO,EXVLAIN PREACTION__ VALVE S Does Eacn Grcuit Operate- Dces eaCh-Cir[uit.Operote- -Mazimum Time-TO -MaHE MOOEL Superv?zion LosfAb?m7 Valve-Releau? 1 Operate-Release: - -MtN. --SEC. - ALL CIPING HYOROSTA71Cqllv TESTED AT ?CJ V5I FOR-2- HOURS Y? Di3Y-PIPINC'i PNEUMATICALLY TESFED: YES -p? 'NO ? - .EQVIVMENT OPERATES PROPERLY: YES ? NO ? TESTS IF Np, 57ATE REASON ' ° ,s'vn: . . .. ? ?._ '• y? Y:'y,. : -- " - =0aATWTESr--i7ElCOTNGOFGA-G'ELOCATD - _'___ - --- -qE51DOP:LPRESSURE.WITH VRWE-IN.- I NEAF WATER_SVPPLY TEST PIPE: TEST PIPE'OVEN'WIOE" STATIC iRE55URE G5I pgI TEST BIANKS- "NUMBE!'L?rcrn__ _LOCAT-IpNS _ DO_VOU CEATIFY-AS'THE SPRINKLEP-CONTqACTOR'TI+ATm--ViELDINGPROCE'JURES-COMPLV,WITH_THE REG VIRE-;-_.: r ? MEDk75=QF=.kWS`•DF10?9:'IcVEL-AR.31 -f'EL-DfNG-- -= DO vQl}=EE^"?-'"-TK.i-T=Fii?WEtD? - FJqL-IF1EQ-YN-CO NCE WITM TNE-'. -REQGIREMENTS OF AWS-D30.9, LEVEI AR_37 ___yES=?---=NO ?_ - _- ? 'OO-YOV_CERT4F_Y LNgT WECUtIVGYFASc[Aita+cn-c?r=?i??nnnRttp,?g_y?e?y?g.J??F ^rcHEA'iE1 _ TROI'PROCEDURE-TO-INSVRE THATALI_DISCS-ARE-RETRIEVEO(THA-T-OPENINGS-IIV-0IPING-ARESMOOFH----- I - TFiAT.-SLAG_.AND?07HER_ WECDING=.RESIOUF-ARE_REMQV.EO:-AND=TMA-T-THE-IN.TE?AIytQY/KMF-TERS-OF m?? ? DATE LEFT IN SERVICE WITM ALLCONT_RpL_KFLJti-O?cN: REMARKS-_='_'. - -._---- -___'-__"'_' "_ _ - _ _ iVaRt?-??'SAIiTIPICCEF[..CQRTR7i.C"fO.R - - - _ ' _ - Y 1" l?? - ??_ ' 't•? ' ",?`V:< i ? .._, _ '_ _ _ _ ?' - - - '?J. -_.' ---- "' FO O N k'(SiG )' -- - TITLE i -51GNAFtiRES- ?- -- - - - _ O IECER- _ ? _ _ ..w.. - - ' '_ T ... . ; . ESTS_Wii- NE55ED-BY= y? - LT.LE_' - - _?Y -DATE- - ' ---_- -, -. ' - OtTI - NAt-' - PLRMATtONS-A'(VD-NQTE5- -- '_- [ ? CONTRACTOR'S MATERIAL & TEST CERTIFICATE -PApTS-A-&_C?SPRtklKLER-&-NlATER=SPRAY-ABOV.EGROUND-PIPING IFiil Out Separate-Certificate-For_Eacd-Riser) PR0_CEDi1RE__ UPON-COMPLET-ION=OF=WORK,-INSGECTION-AND-TES-TS-SHALL-BE'MAOE-BY THE-CONTRACTOIi'S'REP'HESENTATIVE AND"WITf'fESSE?BY'I ' AN OWNER S= REPRESENSAT.IVE:.ALL DEFECTS SHALI. BE CORRECTED AND-SVSTEM-LEFT. IN.SERVICE HEFOR@CON-T-RACTOR'S MEN ' . _F_INALLY-LEAVE-THE JOHc - , A-CERTIFICATESHALL.BE FILLED OUT qNO.51GNED BV BOTH REPRESENTATIYES. COPIES SHALI BE PitEPAREO FOR APVROVfNG I AUTNORITIES'.OWNERS AND CONT-RACTOR. IT IS UNDERSTO00 THEOWNERS-REGI3ESENTATIUE'S SIGNATVRE-IN NO WAY PRE!- UOICES-ANY GLAtM AGAINST CONTAAC?OR FOR FAUC7Y MATERIAL,-PppP-°WORKMANSHIC, OR"FAILUI7E'TO"COMPLV WITN AG- PROVING AUTHORITY'S RERVIREMENT S OR LOCAI ORDINANCES. PROPERTY NAME DATE L' S PROPER7Y AODRESS } , G.Y ?/?. - ,_?--? ??_ .•'??J?(?.-1 -` 4? i ACCEPTED-BrAPPROVING AUTN00.1TYI'S) NAMGS _IWDUSTRIAL- RISK= INSt3RERS a.ooaESS ? PLANS MINNEAPOLIS. MN 85402 - - -INSTAI!.4FION-C6FJF?S_Tc,-4 ol_qu5.,_- - EQCJTPMENF=USED IS APPROVED YES NO ? - CIF NO ,STATEDEVIATIONS r1A5 PERSON-IN-ChARGc:IF FtFE <IIUIPAIENT-'aEcN-IN57AVC±EO A5T0-LOGATIOIV I qP CONTRQI_VALSLES,qNdCA-REAF TH45-^+Ew-EAUIPMENF? YE$_A - --NO ? _ . _ I IF'VESGIYENAME:'"lF-NO, EJCPCAIN. -INSTAUC- TIONS NAVE COPIES OF-APPqpPR1ATE-INSTRVCT10N5=AN0 CRRE=AN?MA9NT-ENANfE-"-- ,y.,? CHARTS AND NFCq 13H BEEN LEFT ON'PRETATSES? -- ' VES-•?,q, NO .O- f iF=Yu; GIVE NAMc:-IF-(VO; EXPL-AIW.- - ---- -HY-QROSTATICr-Hytlrostatic-tesiz?sbau-be-maGe-at-noY-.1ess-tbart'?OOr-P51-(1318=barsrtoctwo baurs°or-50-P5l-13.3=bars) ? --- _ atrmc3l;L'?pceslure-?cr_efcCeg??_5axr=i30.-r-bdrs)=Qi}}DEgFlFidKC¢y-p?pe'val?e-clap0e[SShal?bGiBRt=Op@mQatin¢-te5tLt0. TEST - P«vent tlama9e. All-aGOVegrouncLp,pmgJeaka9e-ihall-be=stoppatl. 710iV - PNEOMATIC_EStabiish ¢0 P51 (2B=trers) a??=Prossuce-an0?neasurc.droYwhichc5nalLnoc-excec634s_P.SCiO-LGare).in 23 I hour5.- Teybprc55urt_tdnk5-at-n0/mal'wa[er 18vG1=anG-dir=pr<smre-anG-m<asure-av°preSSUte°tlro0 wbiCfl'Snall-nOt exCGltl"34i PSI-(0.1-bars)-in 24-nours. TESTS +? C?- - REQUIRED PNEUMATIC: DRV-PIPING- ORAIN L EqUI?h}ENT OGERATION: ALL, _ -SER-V?ES-BL-0G5: LOCATION--. .. -" -M0OEL. -512E.- - - ==-_QVAPrT-IT-Y--- -T-EMP@RATHREAATING SPRINKLERS SPRAV- --"-N022LE5- °'PIPf7ANII---„ MATERIALAN0=K1N6"CONFORMSTp_? - STANOARQ-___- -- _LF.-ne3o+E:.EJCP_LP.?=__ -FIT-71NGS=- - ' A L A R M D'E V 1 C E" MA%IMVM TfME TO OPERAT_E.THROVGH TEST PIPE ' -i1CARWf°VtCLGE--- . -TyPi =MAKE M -MIN_ SE0.-- OFF-fL04Y_ _ TA4 - -INDICAtOR- = FORM -8& AC;- REYLSED AARIL1979 . 'VKINTEO-IN U:SA. FOR' fVAS 4 FCA, INC.. P.O. BOX 739,.MLKISCO:-N:Y• 10569' OVERATING TEST RESULTS: TIME TO TRIP TIC TI ALARM MqKE M EF. THfiOUGH TEST PIGE WATER qIq p ACHED OPERATED DRY ITHOUT WITN IR TEST ryp, Q. 0. 0 • pRE55. PRE55. OVTLE7 pROPERLV PIPE -MIN: SEC. P.S.I. PS.1. P:5.1. MIN. 'SEC. YES -NO VACVES NO, EXPLAIN _ " -OPEitAT-tON- -PryEpMAT"C-G '-ECECTRfC_O-- -FiY6RFVLIG-'? -- -- - UPERVISED: VES ? NO O DETECTING-MEDIA-SUPERVISED: ES ? NO ? OELUGE -DQES"-VALVE=QP=Ffi610FTHEMANUAC'TRIP'ANO/OR"REMOTECON7k0- IONS? -YES`0-"'NO-O & ISTNEREAN AUESSLBLE-FACILIT CN GIRCUIT F ST.ING? VES. ?. NO_El IF NO,EXPIAIN FR EAGTSON- VALVES Does Each Clrcuit Operaie Oces rcuit Operate Meuimum-Time To M MODEL Su rvition loss Alarm7 VaWe'Re 0 rate.Release: YES NO YES NO SEC. ALL PIPING MVDROSTATICALLY TESTED AT P51 FOR?NOURS DRY PIVING PNEUMATICALLVOMOKI °F ? jJAiSTZUQ?1 YES ? NO-? EQUIPMENT-OGERATES-P ? ? t ?? , ,?^ -?'ES ? -NO ? E?{ ?`? '?'tA'A T.ii?WMS? TESTS tF NO, 57ATE REASON ?? ? ?U04A311109M '- -ORAIN-I'ESI-RE/kDTNCOF-GFtGe`-COCR'fED- -KE5fOVAL=FRE55t3Re-Wff-H=VlkCVc IN-- -NEAR WA7ER'SUPPLV TEST PIPE: TEST PIPE_OPEN-WIDE STATIGPRESSVRE P51 P51 NVMBER-}LSE?D- -LQCAUONS- - NIAMHE.R-REM0.kEO TEST BLANKS L ) 'WELDED-PiPING>' YES.:? -NO-O IF YES-.. DO-VOV.CERTIFV AS-THE SPRINKLER.CONTRACTORTHAT WECDING-PRQCEDtIEtESCQMPLY' ITH-TPfE"REQUIRE- 'MENFS?-OF-AWS<-030:9?-LEVEG AR-37 - YES " -- . NOZQ- WELDING DO-YOU-0ERFIFY-THqT-THE-WEL`JIfV6-\4A5-PERFtJRME-D-GY WEL-DERS:QUALIF_iEDdN-COMP-1 NCEW:TH THE - REQVIREMENTS OF-AWS'D30.9, CEVEL AR-3? _ ?'ES _ NO0 _ DO-V OIhCE 0.TI FY--THAT.' W ELD ING-W AiCA R RLE0.0UT-1N-CDMPL'IANC E.W ITHG4-00G1tP1'EI`LT.FD=QLAIIT V'CO N TFOL PROCEDURE TO INSURE-THAT ALL OISCS ARE-RETRIEVED.-TNAF'OPENINGS-IN PIPlNG'ARE'SMOOTN, -- THAT SIAG -ANO- OTHER-WEL-DING-RESfDUE-ARE' REMOVED, AND THAT THE' INTERNAL'D IAMETERS OF - :PIPHJG--ARE=NOT°PEMEFR'R.T.ED?- - --=YES=X,----NO-O- DAT-E L-EFT IN-SERVICE WITH ALL CONTROL VALVES OPEN: -REMARKS.--- - " -- =NikME- OFSPRtMKL'EfYCONTRRLi`OR--- - '- - - --- -- -' t ? ?-?."_l_ " ? l?`IY? ? -? _ ??}_? -?,-?? .- "FOR'p PERTV'O E '(SIGN TITLE SIGNATURE$"— - --- ? ?- - - - ^ 7 - -F012-SRR/NKtER'COI`h ? - ' ' TES.T.S-W1_TNESSED:BV., -TITLE -OATE - ODLRONAL-EKPLANA.TIpNS-AND=NQTES-- --_- _- , ,C46// Q 20 CONTRACTOR'S MATERIAL & TEST CERTIEICATE -PARTS -A-&-C = SARINKLER-& WATER--SPRRY q80VEGR0UND- PIPING (Fi11 Out Separata-Certititate For Each Riser) ' "_ ' ""__- 1i *_ -7 PROCEOUBF UPpN_COMVCET-ION-OF-WORW,-INSPECTION-ANO TEST5-SHALL BE MADE BY THE-CONTaACTOR'S REPRESEN7ATIVE AND WITNESSED 8Y I? AN OWNER'S REPRESENTATIVE.- ALL DEFECTS SMALL BE CORRECTED AND-SVSTEM-IEFTIN F V SER INALLY LEAVE THE-J06:=- ICE BEFORE CONTRACTOR'S"-MEN 'A CERTIFICATE SHALL gE FILIED OUT AND SIGNED BY BOTH REPRESENTATIVES. COPIES SHAI.L BE PREPARED FOR APPROVING AUTHORITIES, OWNERS AND CONTqACTOR 17 - - . IS VNDERSTOOD THE OWNER'S REPRESENTATIVE.'S SIGNATl1RE IN fJ0 WAV PREJ- VDICES -ANY- CLAYM AGAINST CONTF{1CTOW'FOR FAULTY hAATERIAL GO P , O W00.KMANSHIP, OR FAIIVRE TO COMGLY WITH AP- PROVING AUTHORITY'S REQUIREMENTS OR LOCAI OROINANCES. PROPERTV NAME DATE PROVER7Y ADDRE55 ACCEPTED By AVPROVING AUTHORITY('S) NAMES ' IADUSTRIAL RISK_INSURERS = AOORESS PLANS MINNEAPOLI3, MN_53402 -- 'IN$T-ALL-q-TIQN-CONFORMST()--A-CC:EprFn=0?4ry5- - -- - __ "=VO- EpVIPMENT USEO"IS AGCRpVED 1^0-C -YES=? NO ZI IF N ? O, STATE DEVIATIONS "HASPEiZSQN'IN CNARGE OF FIRE EQUIPMENT BEEN lNSTRVCTEO A$ TO_LQCATION ' OF_CONTROI VALVES AND'GA-RE OF-THFS=NEW=EpUiPYkNT? ' -VES-? NO C - " -1NST.RUG IF YES, GIVE NAME, 1F NO, EXPLAIN, TIONS HAVE COPIES OF APPROPRIFTE INSTRUCTIONS-AND'CAREANO.MAINTENFNCE CHARTS ANO NFPA 13A BEEN LEFT ON PREMISES? VES yl NO rJ - - - -1F YES,-GIVE"NAME.- IF NO,-cXPLAIN. - - - -= HYD1705TATIC:'-HyCroStaCiC-tests'stlau be male at noLlai_Man-200 P51 (13_8 _bar5) lor two hOUrs or SC C51 (3.4-bars) , -a0ov<-stat - . TEST -- rc ?refs?rc=rrcexcass=of=.-SG=?$c(.0;3.pars)-0iiferentu?=Cryplpe valve GapOari-siwlPb¢-taK'apen-tlunng test to Pevent-tlamdqe. .All•abaveqround-piping I@aWge-Shall be S2oDPetl.---- -- _ -TION _ _PNEVYtATiC:__EStabli5n-60 P51 (2.8_Gd6)_d??_.,-OTGSSULG=dRQ.-rtfldSUR?tlrdp=W111Cff=5h311-(IOfe%WC-1Y1'P$I (0.1 OdfS)'i1Y24• , -houfi.'-Tes[ ptlSSU18-.tank5.d4nOrmal-wateFl@VEI-antl dR plel5uro dn0 meaSUIG ai! pl85SUre tlrOp wilitfl Sball nOt axe!!E lth PSi-(0.1'bars)'m 24 naws. ' - TESTS 'KYO-RTJSTE1TfC-.-FlR PIPING. 1 11 REQUIRED "PNeUMATIC: DRY PIPING - pRAIN L EQVIPMENT_OPERAT-IOIV:-ALL, . - --- -- 3ERVE5?81LOGS:' - IOCATION ' - -----MA1(E--- - MOOEL - "---SIZE- --- - -_i pG/XNTT/ - EMPERATVRE-0.ATING SPFINKLERS ?L- lCCJ !CE/ -- /--? _SPfiAY -NOZZCES --"-- - =PIPE/CND-- - -MATERIAL AND WND CONF}RMS.TQ - _$TqNDAAO- q _ _ _ .- = _ -- F-NOME.1EJEPI--AIN-- •-- . - - _-_ -_- -- -- FITTINGS A L A R M O E V IC E MAXtMUM 71µE TO OPERATE TNROUGH-TEST PIPE ALARM-VALVE TYpE- _ MAKE -MODEt MIN. SEC. - -OR FLOW- _ , -INDICAT_QR ' __ _ .L?? FORM 85'AC REVISED APR • _ _ LL- 1979 -PRINTERIN U.S.A. FOR NASd_=FCA..INQ,-P.0.-B0%-)1:9.-MT.KISCO,.N.Y.}6549- OPERATING TEST RESVLTS: MAKE M ER. TIME TO TqIP THROUGH TEST PIAE WATER AIR TIP p OIX TI F EACHED qLARM DRV NO. ITMOUT WITH PiiE55 Alfi TEST OPERATED P?pE O. O. o. . GRE55. OUTLET PROPERL?' MIN. 'SEC.- P.S.I. P.S.I. P.5.1. MIN. SEC. YES NO VACVES--"- - " _ NO. EXPI_AIN_ -OPERFT.IQN- "- - pryEUMATIC _ELECTRIC O_ HYDRAVLIC ? SUOERVISED: YES-? -NO-? DETECTING?MEOIA-SUPEAVISED:ES"? NO ? DELUGE =DOE4VAEVE'O - 'FRQM-TMEMANVALTRIPANO/OR-REICAOTE'CONTR ON57 YES -0 NO ? &_. IS--THERE-AN-i4CCE5518LE FACILIT CHCIHCUIT- fNGi" YES Q NO Q IF NO, E%PLAIN I PRF4G'ClON - - VAWES ' Does Eacn-CircWCOpents Does- rtuit Operete Maximum Time To MOOEL Superviswn Lass Alarm7 Valvee Operate Release: YES-- NO- vE5 --NO- -SEC. ALL PIPING HYDROSTATICAL.LV TESTED AT P5I FOR2 MOURS -- ORY PIPING FNEVMATICALLY 7ESTCD: -- , , , - YES ? NO ? EQVFPMEN7OPERATESCROPERLY: VES ? NO ? - ' - ' ' " '"? TE5 T5 -IF NO, 57ATE REASON " `• ' ' ' .. , . . - , -- '?- 70RniN=TESTF°0.EADING OF GAGE IOCATED_ RESIDUAL-PRESSURE-WI-T.M-V-ALV-E-IN I NEAR WATER-SVVGW 7EST PIPE: TEST PIPEOPEN'WIOE STATIC PRESSURE G5I C51 - -NklAt9ER-f;SED- 'IvCATiONS NUMBER REMOV_D TEST_BIANKS_ _ ___ ' -------- - ---- -- WELDED-PIAING?`==' V.ES_:P??_ -N0 ? . . - I IF'YES::._ _ I DO YOU CERTIFY AS THE SPfiINKLER=CONTRACTOR"TMAT-WELOING-PROCEDVRESLOMPLY `K1SH_T.ME-REQLLIRE- , _-' MENTS=UF-RWS'D3'0:9;'LEVEL-AR:Y _VESNO--LI -WEEDING- "?rYOCf-C?FrfRATTr+E'VJELOING WAS PERFORMED-H`i-WECD£ii5 QGAGIFIELTIN?CO I NCE'W1TH THE O RE VIREMENTS-OF AWS-030.9,_LEVELAR•3?___,--_.__-- _-_- --.- ------YE --NO-O-- _ OQ=`LQ?C? EtpING=WASLQR.R{gLL=Q;,ITIN=C?-fiaPEtRFNEE=W1-PFFA=0GC:1bkEft.cv?"r:1A'l'tT=?"wN--"-- __. _ .TROLPROCEOURE TO-INSURE TNAT ALL_DISCS ARE RETRIEVED,-THAT OPENINGS-_IN-PIPING-ARE=5M007H;- ----_-_= JMAT-SEAG.•ANO= OTHER-=WECOING-RE3iOUE -ARE-REMO?/EO,-_AND THAT_TH?IlYiEAM9l.- ?C, AMET.E35=0F - - -" P_1PFN ?AFE?iO'?PENE7:RRT.ED7 _ - NO__Q- DATELEFT=INSERV.ICEWIiFi,AI I C6NTROL.VALKES;OPEN:== -- - - REMARKS - --- . - - N'iChtE-Q?SP'FFifJitl'ER CONTRACTOR -? .i'--- __ 1 F kOPERTY pWNER (SIGNED) TITLE } - ?°SIG7TATUAES- -- - .--. -- ---?:- - - - --- - --- - -- ' ? ' • -? . __ - - " " ' _- " " -_ _ _ T _w =- ----- T-ITLE - .- --"-- - ADOITIONIiC-EXPCANATtONS-ANO NOTES- ? ?- CONTRACTOR'S MATERIAL_&. TEST CERTIFICATE LJ LJ -PARTS-A-&_C--SPRINKLER &--WqTEB SPqqY.ABOVEGROUND-PIPING- (Fill Out-Sepacate-Certificate-Gor Each Riser) ...?E -VPON..COMPLETION-0F-WORKpINSPECTION-ANOTE5T5-SHALL BE MADE 8Y THE CONTRACTOR'S RECRESENTATIVE ANO WITNESSED-BY -AN=OWNER'S REPRESENTALIVE. ALL-DEFECTS SHALL BE CORRECTED-ANOSP FINAI Y + _ . .L -_LEA FEE-LfiFJQ@. STEM LEF_S IN_SERICICE-BEFpRE.CONT-RACTpq'S-MEN - A CERTIFICATE SHqLL 9E FILLEO OVT AND SIGNED BY BOTN REPpESENTATIVES. COPIES SHALL BE Pf3EPARED FOp qppROVING AVTNpRITIES, OWNERS AND CONTRACTOR. IT IS VNDERSTpOD THEOWNERS REP UDICES ANV ' RESENTATIVE S-5IGNATURE IN NO WAY'pREJ_ CLAIM iXGAINST CONTRACT00.'FOR FAVLTY MATERIAL, GOOP W00.KMANSHIP, OR FAILURE TO COMPLV WITH AP- PROVING AUTHORITY•5 REQUIREMENTS OR LOCAL ORDINANCES. PROPERTY NAME DATE PROPER7Y qDORE55 ACCEPTED BV APPROVING-AUTHORITV(•S) NAMES =WDUSTRfAL RlSK-?NSURERS- AODRE55 ' " /?Tl'f'CT-?l-1-ii u) 1a?kGl MMLL _ PLANS MIHN?aous, ? _? _--1NSTFL_AT(ON=?F'OFFtitS:T -" - eQUIPMENT VSED IS ADPqOVED -a0 u IF NO, STATE-DEVIqT.iONS YES- 91 NO-O HAS PERSON IN CM OF EQUIPMENT BEEN INSTRUGTED AS TO LOCAT ION = ??-CONTRCL`LqLCFTHIS-NE`?1-E(?LLIPK.tENT?°-- VES=? NO l IF Y -INST.RUC- E,S, GIVE NAMIN,_ - - ? TIONS . HAVc COOiES'0F-qpp{70PRIATe'INSTROCT:ONS ANO-CAR&AND•MAINTENANCE CHARTSANO NFPq-11A-8EEN-LEFT? N' p PREMISES?-= YES_.? NO ? - 1F YES;-GIVe'NFtMEr-IFNO, EXPLAIN. "---" HYDROSTATIC - - - = ' : NydrostdhC tests_snair:tie?madcaT-nntJess-tnan_ - 240-PSF-(13.H-bars?-tortwo_baut?or_50=P51-?3.4-bari?- ??NV?S:d:iC°p/¢4Stl?e-tr ' y- _TEST g??p/-y5? ._-OiiiRenLdf'tl! ?Pravent-.Oamage.cqp-.abave Y-P'Pe-valve ctappus znall be-lett-open tluring tmLto - 9rountl - Pipinq-leakage-shall-_he stoppetl[_ -- _-OESCRIP.==__ - _ TION PNEiiMATIC: Estabiisn,a0.P51_ (2-8 =Gdrs]-d iFTpraSUfEidittl =ml351ifs-tlr00-whiCh-ShII4l=no:'C%L¢Cd'} Vt PSC(0 1 ?d 24 h : - IS)-1n- - _ oWS. Tast pfe55ure [anks at n0/mal watN leval antl au ptesSUfe dOtl Taasute dv 0/lSiwe Crop- Whi<n Shall Oot_exceeQ 34z P51 (01 -b ' i - _ _ ari) n $4_hour3.___ TESTS H?'QHOSTATIC: ALL PIPING. HEQUIRED ? PNCUMATIC= DRY PIPING DRAIN ------------------ ---EQUIPMENT OGERA7-ION:-ALL:..- ._._ _SE RVESBLLTGS: -' -.- LOCATION 'MODEL" ' -SIZE' pUANTITV _ TEMPE RATURERATING _ SPFINKCERS- J T -14 I ` .-.==QR>__-__ - - - ---- -G?C._? - - --- - - - - - - - ---1_-_ -- --- - - -SPRAY --NOZZCES - - - - - - - -- - - - - - -PiPE .=ANO_^- -_ ' MATERIALANnaKWD_CONFORM5-T0-- -? TANDYCR?---- - -- ---- -' - - . . -'_- -?.......?- -_- "_-.?-,•?rE7FPF,=diY.==- _FITTINGS A /a L A R M-9 E.V IC E MAXIMUM TIME TO-QCERATE TMROUGM TEST PIPE LARM- VALVE T'PE MR!(6 - MOOEL {y?I?y_ gC -OR-FLOPt \./ -INOLCP,TOR = 1f - FORM gS.qC.'REV?sfn aonu ioeo rraw11tu:irv V.S.A. FOR NA5.6_ECA.INC,,P.O. BOX 719 MT.'KISCO.N.Y. 30543 OPERATING TEST RESULTS: - TIME TO TRIP 7Ip TI ALAqM MAKE M TMROVGN TEST PIPE wATER -A1A p ? E ORY NO ?7HOUT WITM P{yE55 AIR T 5T O?ERATED PIPE Q. ?• ? . PAE55. OUTLET PaOPE0.LY MIN: -SEC: 'Gb.i. P.S.I. MIN. SEQ VES NO XA L-VES = -- - ' NO, EXPLAIN _ --PfQEVqf/l7{C_0" =ELECTRIC-O-- MYDRAULIe'? - -SUPERVISED: YES_? Np ? _,DET.EC7ING_MEO1A SUPERV-15E • ES- ? -NO-? 'DELUGE 'DOES-V-ALVE O FROM TNEMANUA'l'FRIP-RNU/OR=R'EMOTECQNT- - IONS? VES O- NO Q .&_ ' IS THERE_AN ACCESSBCE-FAtlLIT CH=CIRCUI -ESTINGi 'Y£5 ? NO O IF NO, EXPLAIN -Pfi EACTI O N - VALVES -OOeiEacn.CircWPOOeraN- -Does- ircuit-Operate- -Maximum7ime?o ' MODEL -Su rvrsion 1o55.Alarm7. Valve e O erate Aelease: =YES NO Y_ES-_ -SEC. ALL PIPING MYOROSTATICALLY TESTED AT P51 FOR?HOURS - DRV PIPING PNEUM0.TICALLY TESTED: t• • YES-V(,- NO ? - , , -EqUIPMENT OPERATES PROPERLV-: 'VES-)RL-, NO ? TE5T5 1F NO, 57ATE REASON }.'vn:_ '-'-""--"- -D"ItFtfN=T'EST:=REAVING'OF-G':4GF-C[7C.4TE0 -- -RESIDOALPRESSOREWITNVAWEIN NEAR..WATER SUPPLY TEST PIPE: TEST PIPE OPEN'WIOE' STATIC PRESSURE P51 PSI -NUM9EELy5E D- LOCi4T10N5- --fYGfHBER-R'EMOVcO- T.EST-BlANKS- - :WEtDERP/PfNG- - - YES NO' G_? - IFYES__ 00 YOU CERTIFY /i5"TFESPR-INKLER-CON?T 0.AE-T.OR=FHAT_WELOMVG-?ROCEDUfiES'COMPLV wITH THE-REQUIRE-- - -- - - 'M-ENTS°OF-=AW5-=010:9, LE'Y-EL AF•31- YESEt 'NO'_U -CNE'tpfNt'i-- -???'Oll=CEWFFFV-THA-T-THE=W2tDYN?pi - - - - - - AtIFiED=iN CaM i NCE WITMTHE- - REQVIREMEIVTS OF AWS 010.9; 1.EVEL AR-3?',_.___ --YES- NO 0... _ __-'_'_ " ' _ - -' 'DO-Y.OU_CERT-IF-Y--.TMAT-W£1?' IN6=Wah??'_RRIZEn-niis=w-rnr.wqo-?..l:?-?-.q-ppGtypTEry-xEp=pty,qtl-fV-?,pN"=-' TROC'PROCEDVRE-TO"INSURE-TMAT ALL_DISCS ARE-RETFTEVED; TNAT OPENINGS-I?PIPINCrARE-SMOOTH, -THATSLAG-AND'OTHER-WECDING _°RESIQUE_AR E=ftEMOVEO=ANO-THAT-T.NE--INTERNA ?QIRMETERS OF " -' 7PtPfIVG--IFiFE-'fV0'PPEIVE-T-R"ATED'.r------ DATE-LEFT IfV SERVICE WITH-ALL'CON.T.RG1_VnL'v.tia7P_EN.- =REMRFK5-- - i e -V , 'F R- PER -rY OW1V '(5 TITCE SIGNATURES - =_- - - - - -- - --- -- ---- - - - ?' -•= " - ? - -C ? ? _ -- . ? - - - - -- == -??-? - - -- - _ - -- - -- - -- - - • G S6T " --- --TITCE DRTE- . . ---- - ---- ADOfT-)ONAI -EXPL'RNATFONS A/VD'NOSES • ' _- - ' -' .- . .--- - .- ? CONTRACTOR'S MATERIAL & TEST CERTIFICATE LJ LI -PARTS A-& C --SPqINKLER-&-WATER -SPRAY -ABQV-EGROUND.PIPING (Fi11 Out Separaze Certificate For Each Riser) -? ?=V:: .?? IPROCEDURE UPON COM?LEfLION_O{--WORK, INSPECTIONAND TE5T5 SHAtL 8E MADE HY THE-CQNTFTCLTOR'SREPRESENTATIVE AND WITNESSED BY AN OWNER'S-REPRESENTATIVE RLL DEF .-- - ECTS SHALLHE--CORRECTED'RNO SYSTEM 6EFT-IN.SERYICE BEFORE_CONTR"ACTOR'S MEN FINALIY-LEAYE-THE JOB. A CERTIfICATE SHALL BE FILLED OUT AND SIGf3ED By BOTN REPRESENTATIVES. COCIES SNqLL BE PRE7ARED FOR APPROVING AUTHpRITIES, OWNERS AND CONTRACTOR ' . IT IS VfYDEA57O00 THE OWNER S-REPRESENTATIVE'S SIC.NATURE IN NO WAY PREJ- VOICES ANY CLAIM AGri1N5T CONTRACTOR-Fp'R FAULTY MATERIAL P P , OO WORKMANSHIP, OR FAILUPE TO COMGLY WITH AP• GROVING AUTHORITY'S FEQVIREMENTS OR LOCAL ORDINANCES. PROPERTY NAME OATE PROPERTY ADORESS ? ? ?J ? i ? " - ACCEPTED 8Y qppqOViNG AVTHORITV('S) NqMES fNDUSTR1Al RlSKiNSURERS AOORE55 UITE- PL'4NS MtNNEJ1POU3, MN 55402 - .IN$?AL?A-T-IdN-COIVFCRU5T0=A[??rEf]'PC.4MS-- ._..Y_,° -_ .?? ` - ^ -EQOIPh1ENT VScD'ISAPPROVED YES-`? ------NO ?]- IF NO, STATE-DEV IAT IONS HAS PETSON-fN-CHARGEOF`FiRE-E(;LIPMENT BEEN WSTRVCTED AS TO WCATION OF CON-T-qpLVALV_3-AN0-CARE OF TMIS.NE'N_EQli1P_MEN.2?-__ YES-4,' NO ? ------ - IF VES, GIVE-NRME. IF ND,-EXPLAIN, INSTR OC - TIQNS HAVECOPIE50FAPPROPRIAT'c INSTRUCTfONS-ANO:CAqE AND-MAINTENP.NCE CHARTS AND NFPA 13A-BEEN=CEF7- -QM1f-PREMlSES2 -YES-_? NO C IF YES,.uiVE-NnMC= IF--NO,-EXPLAIN. --- HVDROSTAT-IC:--Hytlrostac'rnasts3haltbe.matla-at-not9es5-than 200=P51 (13.8 hars) _for-twa-bours or 50 P9 (3.3-bars) - - EbovacstatiL-pee55uee-ie?Cxc¢ss-p-Y-i50-P51=(10,3 bars)?0i?ferenval=ary-pi0a-?aFVe-clappers-5{iall'baf![tapCmQUr?rtg test t0 7E$T Preven[ Eamdge.--All d00vegrountl pi0in9 lealka9e-5halLbmstoppetl. -- OESCR-IP-= - - T:ON pNEUMATi.^: __Estzbbsn,40-P51_($.3-baql-aiFOressure-antl.measuro-drop_whlcnshalLnotceXCGGQ14i-pSf 10.1 bars).m'24, hourS -TeSYpBSSUre-panks at'normal'watar lavel an0 air pressuro anG measure air wessure Grop -wrticRSnall-not -exceeC 1@ P51 (0.1 bars) im 24'-houn_ TESTS -M'WRQSI`H'7`fC-.ltlCPl'PMG. - - ft REQUIRED ? - PNEUMATIG DRY PIPING ORRIN' _EqU1PMENT OVERATION: ALL, - SERVES-6L-OG5--- LOCATION -MA"KE - =MODEL- ---SIZc-- - - -"-Q17kcNTITY?- -- I4iPERATIIRE RATING{ f f ?J SPRINKCERS L 3 - -SPR"AY _ ---- -- _ - U ? ? • - ? ? - - -- NOZ2CE5- - ? PIPE-rYND= _ MATERI.D.L=qtyp-?tUp-CWVFORMS_i - ?' - 57Ai4?/iF8- FFpk?_wvo,- .4N-- - FITTfNGS A L A R-M O E V FC E MAXIMVM TIME TO OPERAiE-7FFROUGN TEST PIPE ALARM VALVE TYPE MAKE M06EL -MfIN. SEC. - -Oa FLpNt ip?..? ??• IfVDICATOR- -••• o? , c. ocu e.rni, yyry- PRLNTED IN U.S.A. FOR MAS-d FCA; iNC., PA:=BQX 739, MT. KtSCQN.Y_ 10549 - OPERATING TEST RESVLTS: MAKE NRTD? ER. TIME TO TRIV THqpUGH 7E5T PIPE WATEii AIR- TIP" p TI EACMED ALARM DRY NO. ITHOI/T WITH pRE55 AIR TEST OPERATED P?pE Q.O.O. . -PRE55. -OUTLET- P0.0PERLV MINr -SEC:- ' "G;S.I.- P.5.1: °R5.1. MIN. SEC. VES NO VALVES -- ' pNEQK.fqT-C__E3---- - -ELECTRIC-O---- ' HYDRAGCI.G Q -PI-SUPERVISE_D.- YE$_? NO ? .-DETECTiNG_MEDIASUP.ERXISED--- 5 ? -NO-O-- DECUGE- -OOES-VALVED -FROM-TFiEMANUAtTRIP=ANO/OR-REMOTE=CQN-T-R NS? YES O N0-? I _&. 45.THERE-AN-ACCE5518CEFqClt,12 - CM-CIRCUIT-F- TING? YES ? -NO O I IF NO, EXPLAIN f PREACTION_ VALVES . Do<s Each Ci.cuit operate- -Ooet. rcwt-0pe2te- -Maximum Time To M =MODEL $u rviS,On LOESAlarm7 Valve-Re Op¢rateR¢Iease: vE5 -NO YES_"__ _-Na__ _ '- -SEC.-- _-_ ALL PIPING HYDR05TATICALIY TESTED AT p5I FOR-2 - HOURS -ORV'GIVING PNEVMA-TICALLY-TESTED: -- . , - YES Vf, NO _? EQUIPMENT OPERA7E5 PROVERLY: -„? VES" 8i=? NO ? 7E5T5 IP NO. STATE REASON . . .. , ' ` ' ' u..: . ?.- , ,.:?l;r .: •. :: - - - ' ---°----- `DR'KetGTES?FCEaCOW aT'-Q?G3?GETQCp'(EC? "-"---- ---RESIDUACPiiE55URE"WITH VALVE IN I NEAR_WATER SUPPI_Y TEST PIGE: -T EST P IPE- O PEN- W I DE $TATIGViiE55URE psI psi N?=?"?A_y1S=J IvCA-T-IvIYS VUM6'aZ-RcMOVciT-' TE ST BLANKS__ _-! -_I- WECDED.-PIPTNG- ------ 'VES-- =__ NO LJ - _- - 00 `/CU CEKTIFY AS TNE $PRINKLER CONTRACTOR-THA-T-W£L-DI'VG PROCEDVFfES LOMPLY WI7H THE REQVIRE----- -- - _" -YES>p?2NO--G : -4Vc1OtNG -oo=votF__fEF?ii?K-T1'.F-i-T?iG=wE-LDrMa?-wst?aeF-POarmED=By=wESOERS=CSVaCrFrED1rv -- Frt'F=wTTF+-THE-- REQUiREMENTS OF AWS 030:9; LEVEI AR3?___ -VES= -NO- 00 VOU _CEP-?CEYTH0.T-WELMA??_Wq.S_CµpRiEP"OtJT IN CQM -M27CZEa7--QJ+??Y?`?-CON-- --- TROI PROCEOLIRE'TO INSVRE'THAT ALL DISC$-ARE RETRIEY.ED THAT-OPENINGS-IN PIRLNG-ARE SMOOTH - - TNAT `SLAG- ANO-OTHER-?WECDING REStOUE RRE_REMOVEO-ANFNTHA-T--TJ?JE INFERNA--DlAMETERS OF I -_ _- DATE-VFT tN_ SERVICE-wiTH_ _FLLCCN'nGCdALVrS..p.'ib--_ _ - REMARKS -._ - " t?_t .? - c,/? ' 1 y-5?-t - ' GERTYOW ER' IGNg -- ---- TIT E SIGNATURES` -` - ?- - - - - - > `i! -_- - //'? - - g ? /- - - -- -FOR-SPRthtltc`c w `. _- __ - • _ TESTSWITAESSID-&Y_- - - - - -_ - 1 -'-- -- -H DtT10MAi-'EX9l=pNATtONS-AMD-NQTES ,- .._ ? CONTRACTOR'S MATERIAL & TPST CERTIFICATE -PARTS-A =&-C-- SPRfNKLEF-&-WATER SPqAY A80V.EGROUND PIPING-(Fiil-Oui Separate Certificate- ForEach-Riser)? - - cr?i ?tur G . PROCEDURE__ UPON COMPLETION-OF WOFK; II4SPECTIONAND4E5T5 SNALL'BE MADE'BY THE-CQNTpACTOR'S'REVRESENTATIVE ANO WITNESSED 8Y ? AN QWNER'S REPRESENTATIVE A . - LL_DEFECTS-SHALL BE CDRRECTED-AND SVSTEM LEFT W SERVICE-BEFORE CONTf3ACTpR'S MEN PINALLK_LEAVE-THE-JQ6. A CERTIFICATE SHALL BE FILLED OVT AND SIGNED BY BOTH FEPtiESENTATIVES. COGIES SHALL_BE PqECARED-FOR APVRpVING AUTMORITIES, OWNERS ANO CONTRACTOR T . I IS UNOER5T00D THE OWNER'S REPRESENTATIVE•5"SIGNA7URE IN NO WAV PREJ• UOICES ANV CCAIM qGAINST CONTRr1CTDR FOR FAVLTY MATERIAI GOOP WORKMANSHIV ., , OR FAI{.VRE TO COMPLV WITH AP- PROVING AVTHORITY'S 0.EQVIREMENTS OR LOCAL ORDINANCES. PROVERTV NAME /` ' e+ ?ATE .?"?GC ?_. `???N D?? 1_ _? 1?.--?1 . . PROPER7Y ADORE55 ? y??? n ` , l ,w= - ACCEPTEO BY-APpqpVING AUTHORITV('S) NAMES - INDUSTRIAL RISK lNSURERS AOD17E55 - L U PIANS MINNEAPOUS, MN 5540Z - -IMS-T-AL-6AFIONcC-ONFORn,tS-TO-ACCEPTED-otZANS: - _,_ ? "EQOIP61EN7-USED I$ APPROVED YES-? -N ? - ? O - IF NO, STATE DEVIATIONS HAS PEi350N-fN-CHARGFOFFfRE-EQUIPMENT BEEN INSTRVCTED AS TO LOCATION OP CCNTROI_VAWES=P.MO CARE OF THIS-NEW_EQWRMENT? VES=.A_ -. --NO-? IFYES,-GIVE NAME. IP NO, EX7lAIN. INSTRUC -_ - TIONS-- NAVE-COPIES OF qpPqdpRIATE INSTRUCTIONS AND CARE'ANO-MAINTENANCE -- - CHARTS ANO NFPA-33A BEEN LEFT ON GREMISES? YES ix NO ? IFYESP-GIVE-NAME1"IF'NO;"EXPCAIN. - - -HYOROSTATIC:"-Hydrostatlr[ertfsffail-be'maEe'at'not bss than"200{P51-(13.8'_bus) for_.wdnours-or 50 P51 (3.40ars) "--- ? '???????Lp°?t??'?Ci5?0f-'i5CaP5F(30.'3=Wt5):-piHereObaY-tlry+yNCVHvO°GappGlSShalkDO"IBR`Open Cunng-tGSt t0 TEST - 7fevenFtlamaga:--qll-aboveground-piping-leakaqe zball ba stoOpeA. _-_.-OESGAIP. _.- T!CN _ PNEUMATIG EsCaplish. dp p51_ (2:LIparS1 air D,eswre -antl -m eazurcCrop wnichsnalLnotcarzceed 3Yi,P51 (p.l.bars)=m 24- ' -- houri. Tast'presswe 'tanks-at.normalwater level-antl-air.=Oreisure- antl-measura airpressure tlrop.wltlch-fhall not'excaetl 1Vx. PSI -(0.3-Darsy in-24-bours. - ---TESTS ITYDROSTATIC-AtL P1PiNG--- -.. ftEQUIfiED 'PNeVMATIC: ORV PIPING DRAIN EQUIPMENT OVERATION: ALL,. -- -- SERVES-BLOGS: ---- - - IOCATION -- ----MAKE-- -1GpDEl--- ""-512E""- --4UANTITY-- TElNPERATOqERATING SPRWKLERS -- - -?- - - - -"- 7 ---- ? ? _ .-pq= SPRAY --- ---- NOZZCES - _ = PiPE-ANO-=?=_ MA7ERIqL-qN0 KINO CON FORM$_TO ' ? ,STAP{ORRO-- _ _ _IFNExetE_ExaLAiN_.. FITTINGS A L A R M O E V I C E -MAXIMUM T-IME TO OPERATE THROUGM TEST PIPE AUIRM VALVE TYPE -MAKE - MODEI. MIN. SEC. OR _FLOW. INOICATOR- -z- cnou e --? ------ -- ?--- --•-- rnuv?cu Irv ua,v., rue'rvI5 &'FOA: ING., a.0.=60Xq19,.M-r KISCO, N.Y.10549 OPERATING TEST pE5VLT5: TIME TO TRIP TIP TI AIARM MqKE M ER. THROVGH TEST PICE WATEH AIR p qCHE? OPERATED ?RY ryp. ITHOUT WITM pqE55. IR TEST -p0.0PEFLV O. O. D. PRESS. OUTLET PIPE MIN: SEC. P.S.I. PS.i. P.Sd. MIN, -SE0. YES NO -=VALVES - -- --- --- - _ -NO.-ExoearN-------- - ------ - - -_ A7EBA.T_ION -- . --GNEF1MAfIC C- --EL-ECTPoIC-O--------?`DRAtJtIC-O"- -'- VPEFVISED: YES ? NO O DETECTING MEDIA SUPERVISED: - E5. ? NO ? DELUGE -OOES?LEILVEQ2 -FROhLTH&MANLAL-TRIPANO/OftREMOTECON-TR6= --ION$? YES-? =NO-rJ IS TMERE ANACCE5518LEFACIIIT CM CIqCU1T- STING7 YES-? -NO O IF Np, E%GL.AIN PREACTION VA W ES Doa Eacn.GrcWt OoeratL Dces' cuit Operete Maaimum Time To n?t MOOEL Su rviz?on Loss Alarm7 Valve Re e Operate Aeiease: YES NO YES NO SEC. ALL VIPING-HVOROSTATICALLY TESTED AT P51 FOR?NOURS DRV'PICING PNEUMATICALLV TESTcD: YES-bp_ "-NO ?"- EQVIPMENT OVERATES PROBERLY: YES-? . NO-Q TESTS IF-NO,STATE FEASON : 14i : i . . ... .:Vs_ - .. ., r-- -DR-AiY-LE54_=.REA-0-tNG-0F6.4GE_LDE.4FEC- . --- RESIOUAL--PF?ESSUREWi-T-1t?VAi?/EiN->? NEAR`WATE17'SUPVLY-TEST"GIPE:- "-"-- "---"TEST-PIVE'"OPEN'WtOE'---- "-- - STATIC PRESSURE P51 PSI fVVktBER EO. .COCATIONS- _ NUMBE0..RcMOVE' TEST BIANKS - - -NO_G"_ w?neaeicE;?s==--- - --- .-- - - ---- ? --ves_ IIFVES. .. - -_ 00-?'OU CERTIFV AS THE SPFiNKLER CDNTRACTOR TMAT WELDING PqOCEDURES_COMPLY WITH TNE R°_QVIRE- N ? O _--- f MENTS A.F_-AWS D10.9p,lEV:E-AR-31...- YES:X-? :_ ? - -WEIO YG-- WEl,4Ei35-pUAL.LEFEO?N-CIIMP?NCE WQ-TNE- 00=? OU-C:.^++iFY 2NFT?"'rsE'N-ELSING-WAS-PEIiF-ORME6=HY I - = REQVIREMENTS OF AWS D10.9, LEVEL AR 3? YES 'No G - I DOC%OU_CERTIFY THAT WE;.D+NG_wA5_tAiiRtEO.OU' IN_CAMPLtANGc_WITH--4_DOGCIMENSEa uUAUTY CON- .. - TROC PROCEDVRE-Tp? INSUFE TMAT ALL DISCS ARE RETRIEVEO TMAT=OPENINGS-"fN PIPING ARE $MOOTH HAT-SLAG AND OTHER WELDING 0.ESIDVE ARE-0.EMOVED, ANO TNAT THE INTERNqL ,OtAMEFERS-0F ? i?EFNGJFAEI'1?PENE"FBf.?T_??".. E5 DATELEFT IN.SERVICE WiTH-AlL-CONTqQLVALt/E5=0PEN: . REMARKS- - --.- - 'M4lvfE-6F-SRfiH?F1GL .e-cvN-FR1tEF0 - ' -"- "'- =51GNATURES- -FOfYP PERTV-OW Ft(51GNED) - - - 7lTlE . - •' .""-- _ - ' - - -, .?._-.? -F6fb5?-R6NK6Ee?Ek7 .6' - - ? _ - - " '= _ V - =16gTE - " ' - - = TITCE, TESTS-WIT-NEg ED'BV==_ S - __ -- _---- _ - ' " - -AQDF. IONRI=EXPI-ANATIOQNS:-AND=ND.2E5= --^- ----4 -- ' _- . 'r ? 1 ? CONTRACTOR'S MATERIAL & TEST CERTIFICATE PARTS A& C- SPRINKLER_&_WA_T_ERSPRAV-_ABOV-EGROLLNDPIPING-IFiU-0ut-5epata[r. Certificate-ForEach-qiserl- L?vF:-f i __#__ -S -aaOceauRr UPON-GOMPIETION OF WORK7fN5GECTION.ANO-TESTS SHA{_L-B£-MHDEBY'THE CDTITRqCTOR`5 0.EPRESENSATNE AND.WITNESSED BY -AN-OWNCR'S-RcPAESENTqTIVE: D L -A L. EFeCT55HALL-BE CORRECTED AND-SYSTEM LEFT IN SERVICEBEFORECON7RACTOR'S-MEN FINALLY-LEAVE THE J08. . A•_CERTIPICATESNALL 9E PILLEa_OUTAND S16TlED-BY-=gOTH REPRESEN7ATtVES:-C09fE5-SHALL BE PREPARED FOR qPPROVING AUTHORITIES. OWNERS ANO CONTRACTOR IT IS • " . UNOERSTO00 THE OWNER 5 REPRESENTATIVE'S SIGNATURE IN-NO WAY PREI- VOICE$ ANY CLAIM AGAINSf CONTRACTOR-POR -FAULTY -MATEAIAI,.PppP WORKMANSHIP OR FAILURE TO COMPLY WITW AP- - , PROVING AUTHOftiTY'S REQVIREMEN75 OR LDCAL OROINANCES. -PRQPEIZTY=NhMtE= / OATE i.."? ? PROPER7Y ADORE55 -_C?--?_ _.__ ? _I??-=?_ - - '?•-? T???? -?? BY "NGPROXING-AUTHpR)TY9'SJ-IVRMt'S - INDUSTRlAL RISK.INSUREAS F PLANS MINNEAAULIS. MN _y$OO't - ION CONFQAMS TO ACCEP7Ep PLqKS.; YES_ - NC ? ' - E(7UIFTv1 EIQT" OSEQ:I.TAPPRCIGEO--- -Yc5" ? - -NO LJ IF NO,_STALE.DEV IASIONS - I HAS-PERSON IN CHARGE OF-FiRE EGUIPMENT.BEEN INSTRUQECAS-T0.LQCA-T-:ON OF CONTRCt VqWES-R.MD C:.RE CF THSS NE'rY EQUIPMENT? YES ? NO ? ?iF`PES GIVE -NAFTE- IFI 'XPtA1 O - _tNST011C- __ , V ; N,- TfONS- HAVE CbPIES-OFqppRpPRIATE INSTRVGTIpNS ANO CAAE AND'MAINTENANCE - ._ CH-ARTSANO NFPA 13H 9EEN LEFT ON-PREMISES? rE5NO O _ IF VES, GNE-NAMH, IF NO, EXPLqIN._ _ HYDROSTATIC: HytlrastabC tGxti snall 0! m846_a[-nOt-Ie55-1Ran;200 P51 (?3E 5ar3)_?or_tw¢ 11ours 0r-50-P5113 4bdr5)? --- _ . _ . _ . atrove statit -pressurc.in_ezcos-C• 350 PS!-(10.3 bars). -Drff¢renuar.ary>pipe_vauey¢ppers.sball_be-Iett-oDea-UUo-ing-tatto- 7EST PFe"nt°damage-A11 abovegrounE pipmg l¢akage-sball Ge StopDetl: - - "_--bESERFP--- - _ -TION- aNEUMATIQ Establisn- aO v5I (2..8_bar5iL3n-oressure-xne measurertlmp which sha11_nnLexcEGG_I1hoSf-(0.1-bars)-m 24 - - hours., TesCOeessuce-Wnks-at-nor-mM:water=lwel•antlair=yressmaran6'-measura air_ pre5wre-dro0.`Mhi<hc5ba11-no0.exteetl l4i . - 'P$I (QI bdri)-in--24-hOYfS:-- -HY6fiQ57ATIC3ALLPIPING.- 11 REQUIRED ? PNEUMATIC: ORY PIPIIVG ORAIN __ EQUIPMENT-OVEkAT10N: ALL„ - SERVES-HLOGS: _COC'ATION -'.__ MAKE --tvtOOE? ---- - -- --SIZE-_ _ - QG![NTfT7'-Y TEUIPERFITU(TERA7.ING _. _"" - SPRINKLEAS --- ' _ ? _U - - _`Ofl -:,- SPRAY- - - " - - __ . -- _ - -NOZZLES --°'=--- --PIPE_AND ___ °h}A?ER4Al-AND-k'INPCONPoRMS'T0-' _ - ' -?`3 - -STANDARO?'" ' ._ - -FtTTiN65- --- - ---- - - -A-L A R M D E V 1 GE MAXIMUM 71ktE TO.OPERATE FMROUGH TE57 PIPE ACAFM VACVE " TYPE- MAKE MOOEL - MIN. SEC. OR FLOW A , t INOICATDR- 1 qC, IaEVtSED qARiL 1479 -PRINTED IN US.A. FOA"NAS 3 FCA. ANC.. P.O..HQX 719, MS.-K15E0.1H-1`-50549 OPERATING TEST RESULTS: TIME TO TRIP ORy MAKE M ER. TNROUGH TEST PIPE WATER Alq T TI A?ARM NO. N OUT WITH pRE55 EACHED TEST OPERATED '-PIPE Z . OUTCET PaOPERIY -VkLV ES MIN.j -fSSEZC.- ' R5.1. PS.I. _ P.5.1. - MIN. $EC. - YES NO_ - " _ _ NO. EXPLAIN -- _ __ _ _ - -- - _ -=PNEUMi1TIC-(_F_-- -- - ELECTtiIG ? MYpRAUUC - ?""' UPERVISEO: YES- Q NO ? DETECTING"MEDIA-SUPERVIS YES ? 'NO' 0- DELUGE -??ES-µ'41?? -?OM-THE-MAryUAbT-RIYqNO/OR`-REMOTE'CO - TIONS? YES -? NO -O- I5 TNER£_qN ACCE5519LE-FqfILIT.-- H-CIRCUI ESTING7- O O YES N Q IF NO, EXPLAIN PREACTION _ VALVES -- - 00es-Eath-Cirewt Operate- -Oces- ircurc Operate- Meximum Time.To MODEI Su rvisioo-lou Alarm-? Va1vrR Operete Release: -- - `/ES- NO- - - YES' ---NO-- -5EC? I I ^f ALL PIPING HYOR057ATICALIY TESTED AT P5I FOR?HpVRS -ORY PtPIN6 iNEUMATICALLV TESTEDe YES ? NO ? - -EQUIPMENT WEFATES PROPERCY;' -Y?_? _NQ a -TESTS IF ND, STATE REASON ? ' " ' ` "' '"?• ' " ' iv.. . . , i... . ,.:Y: p . . - -O'RRTM1I=TE3Tl"-REAOIK?_O?GtiGcLOCATeD- - ---___q£SIQLLALP.RESSVRE-WITH-VAWE-IN---- - - NEAR-WqTER SVPPLV TEST-GIPE: =7EST-PIPE-OPEMWIDE STATIC VRESSURE P51 V51 TEST BLANKS - EO LOCA7-lCIVS-- NUMBc7 RcMOVED --- - -- - ? - - -- . LJ VJEtD°D-PIRfNG _VES_ ' ? Np-? - _ IF vES:. . _- -"-. 00 -VOV-CERTIFY-AS.THESP0.INKI,ER-_CONTqACTOR-THAT-WECOiNG"P0.0CEDURE5-GOMPCY W4THTHE REQUIRE. ' -- - - _._, -MENT4 OP-RWS070.9,-IEVEI-Aii-31_ - yE5 NO ? - -- -'--WELDING- -DO'-YOV-C.E..T-IF-V-TH:.T-Tiie-N'EL"pfNG-KAT-PERFORMED BY CYEt,QEHS C7UALIFI?B IN CQ ? A NCE WITH TH'E. REQVIREMENTS OF AW5=030 9 4 . .-IEVF?AR-3?-""_'_'__ ' '-V-ES-?- -- -NO "El - -- "' --- --'-" ----- _--_ - _ - 'D0=1=QUZCc.4Tl FV=TH/}T-=W EI_(11N " -A G=sv sC-AR-FLED=QtJfit+.KEOMP?tAt^iC?WfT-M=F-EIEGYibtct•KFEi="uG'Al[TY-C6N---' T?OL FRaCEDVFE TO INSVR -T _- - E NAT ALL OISCS-ARE=F[ETRIEVED, THAT_pPE1ViNG5-1N=PfPWCs'AREsSMOOTM,_-- A - S LA AND-OTHER WE ? Y ? ? ?? - LOTG qE51DUE ARE REMOVED,•ANOrTHg]'?y?yN2EF2N AMECER OF FfOT?E1 ? ? vETTF.CT-ED rv0= -- OATE LEFT IN-SEHVICE-WiTH A?.L-CONT.ROL-VA6VE5-07EN: - ARKS._"_`_ _-- " '_- ' KFfafE-OF-"SFRiNIt'CER C'QNTAACTOP ---= SIGNA7UR = F -FRO?E TY-O ER (SIGNE i, : TITLE -- - - -- ' - ' E5-- . - -;_ -' - - - - - - -` -- --.-__- _ - - " ` . - - _ -_' _ - - -?•-• GO R-SPRFRKCESTCQN ? ^ T?TS-=W.7'TKE35ED=8Y _ _ _ _ -- , _ ___?T7TL - _ - ` -- siTE-' ___ '_ _ - AD 16N{[L'Ek IANATFONS ANO-NOTE$ -- - --- - _"""'_ _- "' _- In CONTRACTOR'S MpTERIAL & TEST CERTIFICATE -PqRTS-A=&-C===SPRttJKLEfl==--WATERI?ARAY.:qgpV.EGROUND PIPING-(Fill.Out_Separate Cercifiwte ForEach Riser) P;=L tirr--???I 'se-'?-- I PROCEDi1RE__ URON_CpMVLETION-OF WORK , INSPEGTION-AND TE5T5-SHACLBE MADE 6V"THEC6NTR71C"fOfi'S REPRESENTATIVE AND WITNESSEO OY ' AN OWNER S REPRESENTATIVE. -ALL_DEEECTS SHALI 8@ C00.0.ECTE0 ANO SYSTEM-LEFT-IN SERVICE BEFORE CONTR-ACTOR'S-MEN L INALL_Y__LEAV E -THE-JOB. A CERTIFICATE'SHALI BE FILLED OUT-ANO SIGNED 6Y BOTH REPRESENTATIVES. COPfES SHALI BE PREPAREO FpR-APPROVING AUTHORITIES, OWNEIYS ANO CONTRACTOR. IT IS-UNDERSTOOD THE OWNERS REPRESENTATIVE'S SIGNATURE iN-'NO WAV-PREJ- - UDIGFS ANY CLAIM-AGAINST CONTRACTOR-FQq"-FFULTY MATERIAL, POOP WORKMANSMIC, OR GAILVRE TO COMPLY WITN AG- PROVING AUTHORITY'S RE IR M BU E ENTS OR LpCAL ORDINNNCES. PROPERTY NAME DATE Pi20PER7Y qOORE55 /? ACCEPTEO-BY APPROVING AUTHORITY('S) NAMES -1NOUSTRIAL RlSK INSURERS ADDRE55 ICOLLErMALL UIT PLANS MINNEAPOI.13, MN b5402 -IfY5rA6LA-T-FON-CONFORMS-p_qZCgp7cn_oLqryg;_ :r-YtS -" ---NO=G - EQQfPFTEfJT VSED IS'ACPROVEO YES ? NO G - ? IF Nd, STATEOEV IATIONS HAS?ERSON-IN-CHIiRGE6F-FffSE-EQUIPMENT BEEN INSTRVCTEO A$ TO LOCATIpN OF CUN-TRCJIL-VALVFS-RNO-C:iP.E-Of-7415-NEV/cEQ11PMENT? VES-4- - NG C IPYFS,-GI9ENAME. IF NO, EJ(PLAIN. '-INSIRUC? - T1ON5- HAVE_COPIES OF APPROPRIATE INSTRUCSIONSANOCARE-ANO=MqINTENANCE ,q.,? GHARTS ANO NFPA 13A-BEEN LEFT ON PREMISES? YES V4 -NO 0 IFNES,?GfVEN{YME?IF=NO;'EXPLAIN. ' - - HYDROSFA-T-16-HytlroslaUC-t<scrshall-bc'maCe-a[-rtOt 1e55=than-240-PSl _(13.8 Ears)_{or_twa_nourz-o_r_50 P51 (3.4 bars) -'---_ ? 'ab°ve-T?=A?assmx=?n?esscesr-aY-=i59=???2= :'=:arS?.?IIifferenGal-tlryp?pe=vah.e=ctrppaF?shall=bo-?left'oPen-our?ng.[est to TEST - Prevenf-tlama9e.--qp-abwa9iounE-pipinq-IWkag?shall.bs_stoppeE.-- -=DESCAIP- ? TION PNEGMA7IC:. EStaDiisrt 60 PS (2.8-Oari)-Dir-Oressu2 anc meawrrCrop-wh{?ushaItrnotexceell?h-P51 (0-1-barsJam:26 -- r hour5r -TeSt-preSSUre-tanksaYnOrmaLwdtOt-ICV<I antl-air prassure antl-measure air pres5ure tlrop wiLCb shall not exCeeE 111, -PSP (01 -DarS)- in-26- hauri. -T@STS REQUIRED PNEVMATIC: OflY-PIPING DRAIN EQUIPMENT OPERATION: AIL. - -- SERVFS._gLpGS:_ - LOCATION - -MAKE-- --MODE4--- -StZE- I -"QUANTfTY- TEFAPEK/iT-UAERATING SPRINKLERS _OR_ _--_.-__- - ---SPRAY-. N02ZCES- - - PiPE---AND -_ _ MATERIALANDK[ND-CONFORMS-TO-"" - -STRI - ---- - - .-_• _ lF?NONE7.-.Ei4PLN+N°- -- - - - -FFTTINGS- • . " :4 LA R M D E V I C E -MAXIMUM 71MET0 OvER/iTE-T}+RAUGH TESTVIPE- -`ALARM-VAIVE- --TYPE - MAKE_ MOOEI MIIVc SEC. OR FlAW 1 e -INDICATOR- - - =-+ - - rR1NTED?frv-US.A. FOR-NAS-i FCA,_IiVL., P.O. BOX 714,-MT. K15C0. N.Y.10544 OPERATING TEST FESULTS: DRY MAKE M ER. TIME TO TRIP THROVGM TEST PIPE WATER AIR TIP p TI EA D AIARM II NO, ITHOUT WITH PRE55. 10. GHE TEST OPERATEO pIpE- Q• 0• D. PRE55. OVTLET pROPERLY VA --- -MIN,- -SEC. F-.5.1. MIN, $EC. YE$_ NO WES ---- . NO.-EXPIAIN _ _ - - " - . . - _ - -- 'OPERA-FFON-- -" - -PNEQAfATTC-x:?-- ---ELECTR7C -O- - - - - --- -'-HY.ORAUCtC ? GIPING SUVERVISED: -- - --YES V-l-NO DET.ECTItJG MEDIA-SUPERYISED: YES-$E_--NO-0--- DELUGE DOES--V-qWE=OP_ERATEcEfip145THEMRN@7FET-i31P`AND/OR-iiEHOTE'CONTROLSTATI6N5' YES pl NO-O _&-- 15 THERE AN-A-CCESSIBLE-FArIC1TY Irv-.EAtH CIRCUITFOR-T£5TlNCa? YE$°A NO' ? , IF NO, EXGLAIN PREACTION V ALVES - -Daes EacRClrcwt Oxrete ' Doeteach GrcuitODerate Maaimym Time-To MAKE MOAEL Supervrs.on loss:Alarm? Valve.Release? OperaterRelease:-- YES NO VPS_ NO =MIM. --SEC. ALL PIPING HYOROSTqTICAILV TESTEO AT P51 FOR-2-HOURS ORV-PIPING-PNEVMATICALLY TEST-EO: , , • -YES?NO ? - -EQVIPMENT-OPE0.ATE5 PROPERLY; YES-)?;-, NO ? TESTS IF NO, 57ATE R£ASON .av., . _ < i..,. `• y :S`?1-: . ----- 'pp'AIN-TEST-GE40TNG=6?GAGFEC7CATE?- ___-___-- RESIOVAI PRESStilRE"WfTH WAtiVE IN ? - _ 'NEAR-wATERSOGPLY TESTPiVE: TEST-PIGE OPEN wloE STHTIC PRESSUHE MI 'p51 TEST BLANKS -NUMBE2 Ep- LDC0.LfEIYS- - NUMBE'R-REMOVEu- I - - -W£Li]EO-PIFING "_- - - -_- YE$-? - NO u _ - - - IF YES... I 00 YOV CERTIfY AS-TME SPRINKLER CONTRACTOR-THAT-WELDING-PROCEDCIfiES COMPLY WITI-Y'i'HE-REqCIRE- _ - - _- -MENFS-OF FWS?D10.9 LcVEI'AR 3?- - -= VES?NO u -VJrcL'JIYG- - -00-?'-OII-CEFTiF`?Fr1AT THEWELQIN?WRS r?RPORNfet7"$T-4V?'?'E{t? QV{[EIFFED-if`7-Cr,'FF 1 YEEWRTFHF -- ? REQUIREMENTS OF AWS 0309- LEVEL AF-3 VES =NO ? _ - DO Y9V-GERTLFLr'LEAT WELDrNG-wAS_EA(dptELil]IFiFN=C?MOttµiye?dS:'Cit???tJ??rte,,?-?ED-OUA'C!T- CDN- - - I " - - , ,_ TROL- PROCEOURE TO'INSIIRE THAT A"y. DISCS ARE RETRIEVED, THAT OPENINGS IN-PIGINC. ARE'SMOOSH,--- THAT SIAG AND OTNER WECDINaC--R"ESICMERRE=REMOVED,-AN0-2HqT-_THE-IMSERNA =,p.S- CtPtYY .-A-FiE=NO'1`--PENE-T-"H'RTED? - ? DATE LEFT IN-SERVICE wfTH qLl CONTROL V:.lV'c.i_02'cN<_ - Fl-EMARKS _ >. f? - - 'FOR -P - PERT .OW ER'($ICNEO) TfTIE- - ---- -SIGNATURES-_ -__ __- -_ __" ?-_?' _ - ' ?- _- " - - _ F6R=5P_RINAL-ErZ°CONTRA _TESTS_wLiNESSED-BV'___ _TITLE'_' _ ' 3 _ - ----'-"' ' ' ?? _AD -F-i IV.?E_E]CGLANA'T1Oti$?tN?NOTES - -- _- __- _- _ .:._: . .